Author + information
- Published online June 12, 2017.
- Mariell Jessup, MD, FACC, FAHA, Chair, Writing Committee,
- Mark H. Drazner, MD, MSc, FACC, FAHA, FHFSA, Vice Chair, Writing Committee,
- Wendy Book, MD, FACC, Writing Committee Member,
- Joseph C. Cleveland Jr., MD, FACC, Writing Committee Member∗,
- Ira Dauber, MD, FACC, FAHA, FACP, Writing Committee Member†,
- Susan Farkas, MD, FACC, Writing Committee Member,
- Mahazarin Ginwalla, MD, MS, FACC, Writing Committee Member∗,
- Jason N. Katz, MD, MHS, Writing Committee Member∗,
- Peggy Kirkwood, RN, MSN, ACNPC, CHFN, AACC, Writing Committee Member,
- Michelle M. Kittleson, MD, PhD, FACC, Writing Committee Member,
- Joseph E. Marine, MD, FACC, Writing Committee Member,
- Paul Mather, MD, FACC, FACP, FAHA, FHFSA, Writing Committee Member‡,
- Alanna A. Morris, MD, MSc, Writing Committee Member§,
- Donna M. Polk, MD, MPH, FACC, FAHA, Writing Committee Member,
- Antoine Sakr, MD, FACC, Writing Committee Member,
- Kelly H. Schlendorf, MD, MHS, Writing Committee Member† and
- Esther E. Vorovich, MD, MSCE, FACC, Writing Committee Member
- ACC/AHA/HFSA/ISHLT/ACP Training Statement
- advanced heart failure
- clinical competence
- fellowship training
- heart transplantation
- mechanical circulatory support
- pulmonary hypertension
- training milestones
- transplant cardiology
- ventricular assist devices
ACC Competency Management Committee
Eric S. Williams, MD, MACC, Chair
Jonathan L. Halperin, MD, FACC, Co-Chair
Jesse E. Adams III, MD, FACC
James A. Arrighi, MD, FACC
Eric H. Awtry, MD, FACC
Eric R. Bates, MD, FACC
John E. Brush Jr, MD, FACC
Lori Daniels, MD, MAS, FACC
Susan Fernandes, LPD, PA-C
Rosario Freeman, MD, MS, FACC
Sadiya S. Khan, MD
Joseph E. Marine, MD, FACC
John A. McPherson, MD, FACC
Lisa A. Mendes, MD, FACC
Thomas Ryan, MD, FACC
Chittur A. Sivaram, MBBS, FACC
Robert L. Spicer, MD, FACC
Andrew Wang, MD, FACC, FAHA
Howard H. Weitz, MD, MACP, FACC
Table of Contents
1. Introduction 2980
1.1. Document Development Process 2980
1.1.1. Writing Committee Organization 2980
1.1.2. Document Development and Approval 2980
1.2. Background and Scope 2980
1.2.1. Evolution of AHFTC 2981
1.2.2. Levels of Training 2981
1.2.3. Methods for Determining Procedural Numbers 2981
2. General Standards 2982
2.1. Faculty 2982
2.2. Facilities 2982
2.3. Equipment 2982
2.4. Ancillary Support 2982
3. Training Components 2983
3.1. Didactic Program 2983
3.2. Clinical Experience 2983
3.3. Hands-On Procedural Experience 2983
3.4. Diagnosis and Management of Emergencies and Complications 2990
3.5. Diagnosis and Management of Less Common Clinical Conditions and Syndromes 2990
3.6. Research and Scholarly Activity 2991
4. Training Requirements 2991
4.1. Development and Evaluation of Core Competencies 2991
4.2. Number of Procedures 2991
4.3. Heart Failure 2991
4.3.1. Inpatient 2992
22.214.171.124. Initial Assessment 2992
126.96.36.199. Hemodynamic Interpretation 2992
188.8.131.52. Cardiogenic Shock 2993
184.108.40.206. Decompensated Heart Failure 2993
4.3.2. Outpatient 2993
4.4. Pulmonary Hypertension 2993
4.4.1. Inpatient 2993
4.4.2. Outpatient 2993
4.5. Mechanical Circulatory Support 2994
4.5.1. Inpatient 2994
4.5.2. Outpatient 2994
4.6. Cardiac Transplantation 2994
4.6.1. Inpatient 2995
220.127.116.11. Pretransplant Management 2995
18.104.22.168. Acute Postoperative Management 2995
22.214.171.124. Postoperative Complications 2995
126.96.36.199. Inpatient Heart Transplant Management Following the Index Admission 2995
4.6.2. Outpatient 2995
188.8.131.52. Immunosuppression 2995
184.108.40.206. Chronic Complications 2995
4.7. Shared Decision Making and Palliative Care 2996
5. Evaluation of Proficiency 2996
Author Relationships With Industry and Other Entities (Relevant) 2998
Peer Reviewer Information 2999
Abbreviation List 3001
Since the 1995 publication of its Core Cardiovascular Training Statement (COCATS) (1), the American College of Cardiology (ACC) has played a central role in defining the knowledge, experiences, skills, and behaviors expected of all clinical cardiologists upon completion of training. Subsequent updates have incorporated major advances and revisions—both in content and structure—including, most recently, a further move toward competency (outcomes)-based training, and the use of the 6-domain competency structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and endorsed by the American Board of Internal Medicine (ABIM). A similar structure has been used by the ACC to describe the aligned general cardiology lifelong learning competencies that all practicing cardiologists are expected to maintain. Many hospital systems also now use the 6-domain structure as part of medical staff privileging and peer-review professional competence assessments.
Whereas COCATS has focused on general clinical cardiology, ACC Advanced Training Statements define selected competencies that go beyond those expected of all cardiologists and require training beyond a standard 3-year cardiovascular disease fellowship. This includes sub-subspecialties for which there is an ABIM added-qualification designation, such as advanced heart failure and transplant cardiology (AHFTC). The Advanced Training Statements also describe key experiences and outcomes necessary to maintain or expand competencies during practice, although over time, these will be supplemented by additional lifelong learning statements that address the commitment to sustaining and enriching competency over the span of a career.
The ACC Competency Management Committee oversees the development and periodic revision of the cardiovascular training and competency statements. A key feature of competency-based training and performance is an outcomes-based evaluation system. Although specific areas of training may require a minimum number of procedures or duration of training time to ensure adequate exposure to the range of clinical disorders and to effectively evaluate the trainee, it is the objective assessment of proficiency and outcomes that demonstrates the trainee’s achievement of competency. Evaluation tools may include in-training examinations, direct observation, procedure logbooks, simulation, conference presentations, and multisource (360°) evaluations, among others. For practicing physicians, these tools may also include professional society registry or hospital quality data, peer-review processes, and patient satisfaction surveys. A second feature of a competency-based training program is the recognition that learners develop some competency components at different rates. For multiyear training programs, assessment of selected representative curricular milestones during training can identify learners or areas that require additional focused attention.
The recommendations in the ACC cardiovascular training statements are based on available evidence and, where evidence is lacking, reflect expert opinion. The writing committees are broad-based, and typically include content experts, general cardiology and sub-subspecialty training directors, practicing cardiologists, and early-career representatives. All documents go through a rigorous process of peer-review and public comment. Recommendations are intended to guide the assessment of competence of cardiovascular care providers who are beginning independent practice as well as those undergoing periodic review to help ensure that competence is maintained.
This Advanced Training Statement addresses the added competencies required of sub-subspecialists in AHFTC for diagnosis and management at a high level of skill of patients with advanced heart failure who may also undergo placement of mechanical circulatory support devices or cardiac transplantation. It is intended to complement the basic training in heart failure required of all trainees during the standard 3-year cardiovascular fellowship. The training requirements and designated clinical competencies in this report focus on the core competencies reasonably expected of all AHFTC specialists. It also identifies some aspects of AHFTC that go beyond the core expectations and that may be achieved by some AHFTC specialists based on career focus, either during or following formal AHFTC fellowship training.
The work of the writing committee was supported exclusively by the ACC without commercial support. Writing committee members volunteered their time to this effort. Conference calls of the writing committee were confidential and attended only by committee members. To avoid actual, potential, or perceived conflict of interest arising as a result of relationships with industry (RWI) or other entities, each member of the writing committee and peer reviewer of the document is required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. The ACC Competency Management Committee reviewed these disclosures to identify products (marketed or under development) pertinent to the document topic. Based on this information, the writing committee was selected to ensure that the Chair and a majority of members have no relevant RWI. Authors with relevant RWI were not permitted to draft initial text or vote on recommendations or curricular requirements to which their RWI might apply. RWI was reviewed at the start of all meetings and conference calls and updated as changes occurred. Relevant RWI for authors is disclosed in Appendix 1. To ensure transparency, comprehensive RWI for authors, including RWI not pertinent to this document, is posted online. Peer reviewers, along with their employment information and affiliation in the review process, are shown in Appendix 2. There are no RWI restrictions for participation in peer review, promoting the opportunity for comment on the document from a variety of constituencies/viewpoints to inform final document content. However, all reviewers must disclose all healthcare-related RWI and other entities to participate in the review process, and their disclosure information is posted online. Disclosure information for the ACC Competency Management Committee is also available online, as is the ACC disclosure policy for document development.
Eric S. Williams, MD, MACC
Chair, ACC Competency Management Committee
Jonathan L. Halperin, MD, FACC
Co-Chair, ACC Competency Management Committee
1.1 Document Development Process
1.1.1 Writing Committee Organization
The writing committee consisted of a broad range of members representing the ACC, the American Heart Association (AHA), the Heart Failure Society of America, the International Society for Heart & Lung Transplantation, and the American College of Physicians, identified because they perform ≥1 of the following roles: cardiovascular training program directors; AHFTC training program directors; early-career experts through mid- and later-career experts; general cardiologists; AHFTC specialists representing both the academic and community-based practice settings as well as small, medium, and large institutions; specialists in all aspects of AHFTC, including mechanical circulatory support (MCS), cardiac resynchronization therapy, and pulmonary arterial hypertension; specialists in cardiothoracic surgery, critical care cardiology, electrophysiology, and adult congenital heart disease; physicians experienced in training and working with the ACGME/Residency Review Committee as well as the ABIM Cardiovascular Board and Competency Committee; physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the ACGME and the American Board of Medical Specialties and endorsed by the ABIM; and advanced practice nurses. This writing committee met the College’s disclosure requirements for RWI as described in the Preamble.
1.1.2 Document Development and Approval
The writing committee convened by conference call and e-mail to finalize the document outline, develop the initial draft, revise the draft based on committee feedback, and ultimately approve the document for external peer review.
The document was reviewed by 11 official representatives from the ACC, AHA, Heart Failure Society of America, International Society for Heart & Lung Transplantation, and American College of Physicians, as well as by 35 additional content reviewers, including AHFTC training program directors (Appendix 2). The document was simultaneously posted for public comment from November 1, 2016, to November 18, 2016, resulting in comments from 6 additional reviewers. A total of 445 comments were submitted on the document. All comments were reviewed and addressed by the writing committee. A member of the ACC Competency Management Committee served as lead reviewer to ensure a fair and balanced peer review resolution process. Both the writing committee and the ACC Competency Management Committee approved the final document to be sent for organizational approval. The ACC, AHA, Heart Failure Society of America, International Society for Heart & Lung Transplantation, and American College of Physicians approved the document for publication. This document is considered current until the ACC Competency Management Committee revises or withdraws it from publication.
1.2 Background and Scope
The original 1995 American College of Cardiology recommendations for training in adult cardiology evolved from COCATS (1). After several iterations, COCATS 4 focuses on trainee outcomes that require delineation of specific components of competency within the subspecialty, definition of the tools necessary to assess training, and establishment of milestones documenting the trainee’s progression toward independent competency (2). Ultimately, the goal is for the trainee to develop the professional skillset to be able to evaluate, diagnose, and treat patients with acute and chronic cardiovascular disturbances.
Each COCATS 4 document includes individual task force reports that address subspecialty areas in cardiology, each of which is an important component in training a fellow in cardiovascular disease. Task Force 12 of that document addresses training in heart failure and updated previous standards for general cardiovascular training for fellows enrolled in cardiovascular fellowship programs (3). It addresses faculty, facilities, equipment, and ancillary support. It also addresses training components, including didactic, clinical, and hands-on experience, and the number of procedures and duration of training. Importantly, the COCATS 4 Task Force 12 report did not provide specific guidelines for AHFTC training.
This document focuses on training requirements for cardiologists seeking additional training in AHFTC, a subspecialty of adult cardiology. For training standards related to pediatric heart failure, readers should refer to the SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs Task Force 7: Pediatric Cardiology Fellowship Training in Pulmonary Hypertension, Advanced Heart Failure, and Transplantation (4).
1.2.1 Evolution of AHFTC
In 2008, the American Board of Medical Specialties approved a proposal by the ABIM to recognize the secondary subspecialty of AHFTC. The ACGME approved the training program requirements for AHFTC, effective in 2013. These actions acknowledged the special competencies, knowledge, and skills required to care for patients with advanced heart failure, including the possible use of ventricular assist devices or cardiac transplantation. Over subsequent years, an increasing number of cardiologists have chosen to focus their research and/or clinical practice in this area.
The ABIM requires 3 years of cardiology fellowship training before fellows may sit for the certification examination in cardiovascular medicine. Cardiologists seeking additional certification in AHFTC must complete a 4th year of training that provides focused experience with a variety of heart failure patients and procedures, as outlined in the following text.
1.2.2 Levels of Training
COCATS 4 updated standards for training fellows in cardiovascular medicine and established consistent training criteria across all aspects of general cardiology, including heart failure (3). For the cardiovascular fellowship, the following 3 levels of training are delineated for training in heart failure.
▪ Level I training, the basic training required of trainees to become competent consultant cardiologists, is required of all fellows in cardiology, and can be accomplished as part of a standard 3-year training program in general cardiology.
▪ Level II training, also described in COCATS 4, refers to additional training that enables some cardiologists to perform or interpret specific procedures or render more specialized care for patients with certain conditions. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiovascular fellowship, depending on their career goals and use of elective rotations. In the case of heart failure, Level II training is intended for individuals seeking expertise in caring for heart failure patients, particularly those with more advanced and challenging syndromes. Level II emphasizes more detailed hemodynamic assessment of these patients and focuses on transitions of care for patients with heart failure as well as the systems of care necessary to avoid hospital admission or readmission. Level II training also prepares individuals to perform initial screening of patients cared for at nontransplant/nondurable MCS facilities for advanced therapies, in collaboration with Level III–trained experts at advanced therapy sites.
▪ Level III training, the primary focus of this document, requires training and experience beyond the cardiovascular fellowship for the acquisition of specialized knowledge and competency to render advanced care for patients with specific conditions. Level III training is required of individuals seeking subspecialty board certification in AHFTC. Trainees in AHFTC are expected to have completed 3 years of a cardiovascular fellowship and achieved Level I competency as described in the ACC’s Core Cardiovascular Training Statement (2) and the COCATS 4 Task Force 12 report (3) before beginning the AHFTC fellowship. Level II training may be completed prior to or in conjunction with Level III training.
1.2.3 Methods for Determining Procedural Numbers
The recommended number of procedures performed and interpreted by trainees under faculty supervision has been developed based on the experience and opinions of the members of the writing group; previously published competency statements and COCATS documents; and policies of the ACGME, ABIM, and United Network for Organ Sharing. In addition, the writing committee surveyed AHFTC training program directors for additional insight into procedural volumes. Of 69 directors of ABIM–recognized training programs, 21 responded. The procedural volumes and number of technical experiences suggested in this document were considered the minimum necessary to expose trainees to a sufficient range and complexity of clinical material and allow supervising faculty to evaluate the competency of each trainee. These procedural numbers (see Section 4.2) are intended as general guidance, based on the needs and progress of typical AHFTC trainees in typical programs. Those considering these thresholds should bear in mind the fundamental nature of educational milestones—that proficiency and outcomes, rather than length of exposure or the exact number of procedures performed, are the dominant requirements. Flexibility is inherent to this concept, and the ACGME mandates that all programs establish milestones for the acquisition of various competencies by trainees during the course of fellowship training.
2 General Standards
Engaged faculty committed to teaching are critical to the success of an AHFTC training program. Faculty must include specialists with broad knowledge of and experience in advanced heart failure, including advanced therapies and end-of-life care; management of patients with temporary and durable MCS devices and their complications; and care of heart transplant recipients, including management of acute and long-term complications. The most recent ACGME Program Requirements for Graduate Medical Education in AHFTC require a single designated program director and at least 1 additional key clinical faculty member for every 1.5 fellows (5). Each of the key clinical faculty members should be currently certified in AHFTC by the ABIM and be able to dedicate, on average, 10 hours per week throughout the year to the educational program. In addition to developing, implementing, supervising, mentoring, and evaluating the fellows' clinical and research education, at least 50% of key clinical faculty members must also demonstrate productivity in scholarship, specifically, peer-reviewed funding and/or publication of original research, reviews, editorials, case reports, or textbook chapters.
Required facilities include designated areas for outpatient and inpatient care of patients with heart failure. Inpatient facilities must provide a safe and effective environment for optimal management of patients with heart failure of varying severity, ranging from mild decompensation to refractory cardiogenic shock. A safe and sterile catheterization laboratory is necessary to provide instruction in right heart catheterization and endomyocardial biopsy. Trainees should have access to operating rooms and staff to enable observation of ventricular assist device implants, heart procurements, and transplant surgeries. Trainees should have access to outpatient facilities supported by dedicated nursing staff providing exposure to coordinated longitudinal management of patients with chronic heart failure as well as training in the consultative aspects of outpatient heart failure cardiology. There should be an established system to promote effective transitions of care that ensures open communication between caregivers in the outpatient and inpatient settings. Access to an HLA laboratory should be provided. Appropriate space for didactic conferences should be available. Quality and safety initiatives should be in place to assess quality of care and clinical outcomes longitudinally across inpatient and outpatient arenas throughout the healthcare system.
Cardiopulmonary exercise stress testing equipment is necessary for education in the performance and interpretation of this crucial modality in patients with heart failure. Additional technology that aids in the diagnosis, risk stratification, and management of patients with heart failure, such as echocardiography, transesophageal echocardiography, computed tomography, magnetic resonance imaging, positron emission tomography, invasive angiography, and electrophysiology facilities, should be available. Equipment for interrogation of implantable electronic devices, including cardiac resynchronization therapy and implantable cardioverter-defibrillators should be available for both inpatients and outpatients. Trainees should have access to catheterization laboratories equipped with both thermodilution and Fick-based modalities for measuring cardiac output. Equipment for management and interrogation of durable MCS devices (e.g., Heartmate, HeartWare, or Total Artificial Heart) should be available so trainees gain proficiency in their use. When institutionally available, temporary, nondurable MCS devices including but not limited to intra-aortic balloon pump, TandemHeart, Impella devices, and/or extracorporeal membrane oxygenation should be accessible to trainees. It is not expected that each institution will have all of these devices, but every center should have some. At all facilities, resuscitation equipment must be readily accessible.
2.4 Ancillary Support
Level III trainees should communicate with ancillary personnel to ensure comprehensive, evidence-based care. Critical to success is collaborative interaction with various physicians from within cardiology, including interventionalists, advanced imaging specialists, electrophysiologists, congenital heart disease specialists, and other fields of general medical and surgical practice, to address and treat the multiple comorbidities often seen in heart failure patients. Key specialties include but are not limited to cardiac and transplant surgeons, palliative care practitioners, infectious disease specialists, gastroenterologists, hepatologists, nephrologists, pulmonologists, pulmonary hypertension (PH) specialists, and experts in sleep medicine. In addition, communication with primary care physicians, geriatricians, obstetricians, endocrinologists, and oncologists is important for specific patient populations. Also essential is interaction with vital healthcare professionals including nurse practitioners and physician assistants, nurses, pharmacists, dieticians, physical and occupational therapists, and social workers.
3 Training Components
3.1 Didactic Program
Didactic instruction may take place in a variety of formats, including lectures, journal clubs, grand rounds, clinical case presentations, research conferences, simulator-based training, and patient safety or quality improvement conferences. Discussions should focus on heart failure, PH, MCS, heart transplantation, and the medical knowledge items outlined in Table 1. Case conferences, in particular, will allow AHFTC trainees opportunities to reflect on and learn from complex cases, generate ideas for stabilizing or improving patients’ health status and systems of care, and develop skills as team leaders and educators. Journal clubs bring advances in the field to trainees and provide opportunities to critically review published literature, including assessments of validity and generalizability. Neither the most recent ACGME Program Requirements for Graduate Medical Education in AHFTC (5) nor the COCATS 4 Heart Failure report (3) specifies the frequency of didactic instruction, but weekly didactic sessions are a reasonable goal. Moreover, training programs should emphasize to AHFTC trainees the importance of lifelong learning that does not end upon completion of fellowship. For example, trainees should develop the ability to incorporate new therapies and technologies into practice.
3.2 Clinical Experience
Level III training in advanced heart failure requires rigorous clinical experiences in both the outpatient and inpatient settings, including the intensive care unit. In each clinical setting, trainees should participate in supervised patient care and act as a first-line consultant for a portion of the training period with appropriate and timely backup from attending AHFTC physicians. In this capacity, Level III trainees are expected to gather accurate, essential information from all sources, including medical interviews and record review, physical examination, cardiac device interrogation, and diagnostic procedures, including echocardiograms and hemodynamic evaluations. In addition, trainees should issue informed recommendations about preventive, diagnostic, therapeutic, and palliative options and interventions based on clinical judgment, scientific evidence, and patient preferences, ultimately developing, negotiating, and implementing patient management plans. Further, they should develop the skills necessary to competently perform the diagnostic and therapeutic procedures considered essential to the management of patients with advanced heart failure, including those undergoing MCS or cardiac transplantation. Training programs must provide access to a patient population of sufficient size and diversity to nurture these competencies. Multidisciplinary meetings, including participation in the transplant selection committee, are important parts of the trainee’s clinical experience.
3.3 Hands-On Procedural Experience
Hands-on experience is required for successful training, and trainees should be exposed to the full spectrum of AHFTC procedures. Level III training in AHFTC requires competence in right heart catheterization and endomyocardial biopsy, acquired through experiences in the catheterization laboratory. Troubleshooting of right heart catheters in the intensive care unit provides additional expertise in the use of invasive hemodynamic monitoring, including recognition of artifact. Review of endomyocardial biopsy specimens with pathologists facilitates skill in the assessment of rejection. AHFTC trainees must become familiar with the programming and interpretation of data stored in implantable cardioverter-defibrillators and cardiac resynchronization therapy devices, which can be acquired by device interrogation. Experience in the indications and management of MCS devices providing temporary hemodynamic support of critically ill patients with heart failure is essential, recognizing that criteria for selection of specific devices may vary. AHFTC training includes exposure to implantation, interrogation, and adjustment of durable ventricular assist devices under echocardiographic guidance. Supervision of cardiopulmonary stress tests promotes expertise in this modality. Training should also include end-of-life discussions, shared decision making, and communication with patients about advance care planning. Depending upon institutional capabilities and trainee interest, additional procedural experiences may include implantation and/or monitoring of pulmonary artery sensors, invasive assessment of patients with adult congenital heart disease, performance and interpretation of the results of pulmonary vasodilator challenges, assessment of exercise hemodynamics, or implantation of temporary MCS devices. The numbers of procedures that should be completed during the 12 months of AHFTC are summarized in Section 4.2, and the approach to evaluation of competency is in Section 5.
The field of advanced heart failure is rapidly evolving with the introduction of new technologies. Although specific training requirements cannot be provided for all of these, Level III AHFTC trainees who intend to perform these procedures are expected to undergo the same training as required for faculty members performing them.
3.4 Diagnosis and Management of Emergencies and Complications
All trainees should be certified in advanced cardiovascular life support and well versed in the recognition and management of complications and emergencies encountered in the advanced heart failure population. Examples include cardiogenic shock, such as INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) 1 patients; life-threatening arrhythmias, such as ventricular tachycardia storm and complete heart block; severe cardiac complications in pregnant patients; respiratory failure in patients with heart failure and concomitant pulmonary illness; severe rejection with allograft failure; or life-threatening infection in immunosuppressed transplant recipients. Complications of endomyocardial biopsy and pulmonary artery catheterization should be recognized and managed, with emphasis upon knowing when to seek assistance from an interventional cardiologist or cardiothoracic surgeon in such circumstances as cardiac perforation or pericardial tamponade. Trainees should be taught to recognize and initiate management for complications of MCS devices, including thrombosis, stroke, infection, bleeding, and pump malfunction. They should be familiar with advanced life support in patients receiving mechanical support (6). All such complications should be documented and reported in accordance with institutional requirements and reviewed at patient safety or quality improvement conferences.
3.5 Diagnosis and Management of Less Common Clinical Conditions and Syndromes
Level III trainees should become familiar with less common conditions associated with heart failure symptoms. These include myocardial noncompaction, hypertrophic cardiomyopathy, cardiac amyloidosis, muscular dystrophy, arrhythmogenic right ventricular cardiomyopathy, glycogen storage disease, congenital heart defects, sarcoidosis, hemochromatosis, and pulmonary artery hypertension, as well as other infectious, nutritional, and autoimmune conditions. Several uncommon inflammatory conditions have the potential to cause cardiomyopathy and heart failure, including fulminant giant cell myocarditis and acute hypersensitivity myocarditis. Metabolic or endocrine disorders such as pheochromocytoma and acromegaly can lead to cardiomyopathy and heart failure. Other less common conditions presenting as heart failure include cardiac neoplasms, constrictive pericarditis, or acute right ventricular failure (RVF). The Level III trainee should be aware of these less-common conditions and understand their pathophysiology and management. The Level III trainee may not be expert in managing these conditions, but should be able to stabilize patients with them and seek guidance from the literature and from experts.
3.6 Research and Scholarly Activity
All trainees are expected to carry out research and/or engage in scholarly activities during Level III training in AHFTC. Scholarly activity related to heart failure, PH, MCS, or transplant cardiology may include original clinical, basic science, translational, or interdisciplinary research; quality improvement activities; presentation at institutional, local, and national meetings; and publication of original papers, reviews, chapters, or case reports. Trainees should be encouraged to develop and maintain habits of self-learning and continuous professional improvement by reading heart failure and heart transplantation journals and attending journal clubs, conferences, and appropriate scholarly meetings. A trainee’s progress in research should be monitored by mentors through general oversight, direct observation, and critical review of presentations and manuscripts.
4 Training Requirements
4.1 Development and Evaluation of Core Competencies
Training requirements in AHFTC address the 6 general competencies promulgated by the ACGME and endorsed by the ABIM: 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 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 milestones reported to ACGME. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs.
Table 1 depicts the 6 competency domains and their associated curricular milestones for training in AHFTC, as well as examples of evaluation tools suitable for assessing competence in each domain. The focus of this document is on delineation of the core competencies expected of all trainees in AHFTC upon successful completion of a standard 1-year ACGME–accredited AHFTC fellowship. These competencies are marked under the column “All.” Certain areas of advanced knowledge or procedural skills are not typically encountered enough during a standard 12-month period of training to develop and demonstrate competence, and therefore, require additional dedicated exposure. These selected Level III competency components are designated in the “Add” column of the table, usually require additional training, and represent a skill level beyond that necessary for AHFTC certification. One year of formal training beyond the standard 3-year general cardiovascular fellowship, for example, is unlikely to confer expert competency in the management of the most complex patients undergoing heart transplantation or ventricular assist device implantation or those requiring other more specialized knowledge or procedural skills. These additional competencies may be obtained during or after the standard AHFTC fellowship, depending on the trainee’s career focus and the opportunities available at the training program. The milestone interval indicates the stage by which the typical trainee will have achieved a particular competency. Although the competency components included in the “All” column should be achieved by all trainees and are appropriate areas for assessment, not every component needs to be individually assessed in every trainee. Rather, as with all educational activities, assessment is a sampling process that should be tailored to the needs of the individual trainee and program.
4.2 Number of Procedures
An essential component of training an AHFTC practitioner is robust understanding of the indications for, contraindications to, and complications of procedures commonly performed in patients with advanced heart failure, including ventricular assist devices and cardiac transplantation (Table 2). Each trainee should maintain a record that documents the indications, outcomes, and diagnoses associated with procedures that he or she performed or attempted, along with the name of the supervising faculty member.
It is axiomatic that direct supervision of invasive procedures performed by trainees must occur until the trainee demonstrates sufficient proficiency and judgment, attainment of which must be documented by the Program Director. Faculty members must teach and supervise trainees in the performance and interpretation of procedures. Trainees must participate in preprocedural planning and postprocedural management.
In addition to the skills to safely perform procedures, the trainee must possess the skills to determine the appropriate procedure, obtain and interpret procedural data, and utilize the data to optimize patient care. The suggested minimum procedural volumes during AHFTC training are shown in Table 2.
4.3 Heart Failure
The AHFTC trainee should know the pathophysiology of heart failure at the molecular, cellular, and organ levels, including the roles of neurohormonal activation and ventricular remodeling in disease progression. They also should know the diagnostic and management strategies for patients with heart failure due to ischemic and nonischemic forms of heart disease, including infiltrative cardiomyopathies, inherited cardiomyopathies, and cardiomyopathies related to endocrinopathy, pregnancy, chemotherapy and other toxins such as illicit drugs, as well as those with adult congenital heart disease (3). Trainees should become proficient in the management of both acute and chronic heart failure using available pharmacotherapies, and acquire a deep understanding of the evidence base developed from randomized trials that underlie guideline-directed therapies (7). They should be familiar with the epidemiology, common genetic abnormalities, and risk factors for heart failure and know how to assess and manage commonly encountered comorbidities in patients with heart failure. The AHFTC trainee should develop the skills to identify advanced heart failure, direct an evaluation, and determine the appropriateness of patients for cardiac transplantation, MCS, or palliative care (3).
The AHFTC trainee should learn the pathophysiology and epidemiology of various acute heart failure syndromes, including coronary ischemia, accelerated hypertension, decompensated heart failure, cardiogenic shock, and right heart failure, in patients with and without heart transplantation or MCS. As the prevalence of heart failure with preserved ejection fraction is approximately 50%, trainees should know the pathophysiology (e.g., impaired diastolic relaxation, myocardial stiffening, ventricular-arterial coupling), clinical presentation, differential diagnosis and management of acute decompensations of patients with this type of heart failure. Trainees should also become skilled in selection of an optimal diuretic regimen, know the role of vasodilator and inotropic therapy, employ measures to prevent thromboembolic complications, know criteria for discharge of hospitalized patients with heart failure, and facilitate safe transition to the outpatient setting.
220.127.116.11 Initial Assessment
The AHFTC trainee should rapidly identify patients with heart failure in danger of hemodynamic collapse or death and know how to stabilize them. A key element of the initial assessment is to identify factors that precipitate hospitalization for heart failure. In addition, proficiency in obtaining a history and performing a physical examination is essential to assessing a patient’s hemodynamic profile (8), and this must be integrated with hemodynamic and physiological data in patients presenting with decompensated heart failure.
18.104.22.168 Hemodynamic Interpretation
Although invasive hemodynamic monitoring is not routinely indicated in the management of patients with acute heart failure, trainees should become familiar with indications for pulmonary artery catheterization as supported by the 2013 ACC/AHA Guideline for the Management of Heart Failure (7). Trainees should acquire the skills to troubleshoot pulmonary artery catheters in the catheterization laboratory and intensive care unit, and to interpret hemodynamic parameters measured by this technology, including right atrial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output and index, and derived variables including pulmonary and systemic vascular resistances. Trainees should learn to utilize echocardiographically derived estimates of filling pressures and cardiac output to guide therapy.
22.214.171.124 Cardiogenic Shock
The AHFTC trainee should recognize and stabilize patients with cardiogenic shock, and distinguish this from other causes of shock. Trainees should learn the indications for, contraindications to, and clinical pharmacology of intravenous vasopressor and inotropic agents in patients with advanced heart failure, and recognize patients chronically dependent upon these agents. Trainees should promptly identify patients with refractory cardiogenic shock and assess candidates for temporary MCS devices in the context of long-term treatment goals (implantable ventricular assist devices, explantation after myocardial recovery, heart transplantation, bridging to decision, or palliative care). Familiarity with available temporary support device is crucial, and trainees should troubleshoot temporary MCS devices in conjunction with a multidisciplinary team. Trainees should know the role of palliative and hospice care in patients with advanced heart failure. Ongoing care should address symptom control, psychosocial distress, health-related quality of life, end-of-life care, caregiver support, and access to evidence-based disease-modifying interventions.
126.96.36.199 Decompensated Heart Failure
Trainees should become proficient in supervising patients hospitalized with decompensation of chronic heart failure through initial stabilization and optimization of therapy. Management issues include optimizing volume status through selection of an appropriate diuretic regimen, recognition of risk factors for the cardiorenal syndrome, implementation of inotropic therapy when indicated, considerations in use of renal replacement therapy, conversion from intravenous to oral diuretic medications, and initiation or modification of guideline-directed medical therapy during the hospitalization and at discharge. Trainees should become facile with other aspects of management that may arise during hospitalization, including treatment of arrhythmias, interrogation of implantable cardioverter-defibrillators or cardiac resynchronization therapy devices to determine arrhythmia burden and functionality of the device, and assessment of the role of coronary revascularization. Trainees should be able to identify patients whose clinical course is on a downward trajectory, including those who should receive MCS, cardiac transplantation, or end-of-life care. Trainees should become proficient in facilitating safe transitions of outpatient care that minimize the likelihood of readmission for heart failure.
Trainees should learn the various methods of classifying heart failure, including the ACC/AHA stages, New York Heart Association functional classes, and INTERMACS profiles, as well as the epidemiology and risk determinants applicable to patients with heart failure with reduced and preserved ejection fraction. The AHFTC trainee should learn how to direct the outpatient evaluation of patients with recently identified heart failure to identify specific etiologies and understand the role of genetic testing. Various tools are available to assess patients with heart failure, including the clinical history and physical examination, multimarker risk scores, quality of life assessments, natriuretic peptide testing, stress testing including cardiopulmonary stress tests, and noninvasive imaging techniques. Trainees should become comfortable with each of these modalities and know their strengths and limitations. Trainees should learn how to up-titrate guideline-directed medical therapy to achieve appropriate targets. Clinical deterioration in an outpatient and indications for hospitalization should be recognized. Trainees should learn how to incorporate advanced care planning and end-of-life discussions in the outpatient setting.
4.4 Pulmonary Hypertension
PH treatment involves important elements of hemodynamic management of pulmonary artery pressures and right heart failure. The AHFTC trainee should be able to manage, or co-manage with a PH care team, patients with PH from class I to advanced class IV stages.
AHFTC trainees should learn how to detect clinical deterioration in hospitalized patients with PH, adjust treatment accordingly, and stabilize those with acute RVF using parenteral therapies in conjunction with a multidisciplinary team. Further, they should learn the appropriate use of invasive hemodynamic monitoring and know when to refer patients to a PH specialist.
In coordination with a PH care team, the AHFTC trainee should learn to classify patients according to the World Heart Organization criteria regarding etiology, risk-stratify patients with respect to treatment requirements, understand the role of exercise testing, and initiate guideline-based therapy for patients with PH, cognizant of the pharmacological options for PH, including combination therapies and their side effects. The trainee should recognize clinical worsening, adjust treatment as necessary, and appropriately refer patients for more advanced PH care, including balloon atrial septostomy or lung transplantation.
4.5 Mechanical Circulatory Support
A much broader group of individuals will seek competency in advanced heart failure cardiology than will directly manage patients with durable left ventricular assist devices (LVADs) on a daily basis. Nevertheless, MCS is an important therapeutic option for patients with advanced heart failure, including those with cardiogenic shock, and all AHFTC trainees should acquire competency in the use of these technologies. Trainees should understand the results of relevant clinical trials and registry data, maintain currency on contemporary guidelines for management of patients with mechanical support (9–11), and keep abreast of emerging MCS technologies. It is essential that trainees learn to identify appropriate candidates for temporary hemodynamic support and durable ventricular assist devices. Trainees should appreciate the value of a multidisciplinary team approach to MCS by fostering collaborative relationships with cardiac surgeons, intensivists, advanced practice providers, social workers, infectious disease specialists, palliative care specialists, ventricular assist device coordinators, and other team members.
The trainee must acquire the medical knowledge and clinical skills to identify candidates for temporary and/or durable MCS, including those needing biventricular support. The trainees should know the indications for and contraindications to temporary hemodynamic support, be able to troubleshoot devices used in their institution, and develop skills to manage patients in the early post-implant period in conjunction with the multidisciplinary team.
Patients on durable LVAD support may present with a variety of complications. These complications include RVF, gastrointestinal bleeding, driveline infections, arrhythmias, pump thrombosis, and aortic insufficiency. The trainee should know and recognize risk factors for these complications, and understand how to manage them. Because early RVF portends a poor prognosis following LVAD implantation, the trainee should recognize preoperative risk factors for RVF, understand perioperative management strategies aimed at minimizing risk of RVF, and appreciate circumstances in which biventricular support or transplant may be indicated. The trainee should master the skills necessary to manage RVF that develops after LVAD deployment. The skillset must also include: 1) understanding of durable LVAD device parameters and how to interpret or manipulate changes in these parameters in clinical context; 2) management of anticoagulation; 3) recognition and management of pump thrombosis; 4) development of professional rapport with surgical, gastrointestinal, and infectious disease colleagues, all of whom play an integral role in helping to manage LVAD complications; and 5) management of patients facing imminent death, including relief of symptoms. Interested trainees should develop the abilities to perform and interpret ramp echocardiograms to assess likelihood of LVAD thrombosis, although these skills may require additional training beyond the typical 12-month AHFTC fellowship.
Finally, because failure to communicate openly and fully with patients and caregivers may contribute to unrealistic expectations or unmet needs for care, the trainee should master the ability to communicate effectively regarding prognosis, level of understanding, and end-of-life preferences, and foster a close working relationship with palliative care specialists.
Patients supported with durable ventricular assist devices require frequent monitoring in the outpatient setting. The trainee should develop the skills to manage patients in this setting, including: 1) optimal titration of pharmacotherapies for heart failure, hypertension, and anticoagulation; 2) diagnostic interrogation of device-specific pump parameters to inform therapy, including optimization of LVAD speed; 3) identification of complications that require hospital admission; and 4) recognition of patients with left ventricular recovery who may benefit from device explantation.
4.6 Cardiac Transplantation
The 12 additional months of an AHFTC fellowship required for Level III training may not provide the experience in cardiac transplantation required for qualification as a heart transplant physician under United Network for Organ Sharing criteria (12). A broader group of individuals will seek competency in advanced heart failure cardiology than will directly manage patients undergoing cardiac transplantation. Nonetheless, many programs offer an experience within the Level III curriculum to establish competency in the care of patients undergoing transplantation that meets the United Network for Organ Sharing criteria.
Most importantly, through interaction with a wide variety of patients at different stages in the transplant process, with different levels of acuity, socioeconomic and cultural backgrounds, healthcare knowledge, and preferences, the trainee will acquire necessary competence and expertise in pretransplant and post-transplant management, as outlined in the competency milestones (Table 1).
188.8.131.52 Pretransplant Management
Trainees must learn the approach to recipient selection, focusing on identification of candidates ill enough to merit transplantation yet free of medical or psychosocial contraindications (13), and also know how to evaluate the quality of a potential donor heart. Trainees should learn United Network for Organ Sharing allocation listing policies, including when to apply for exception for candidates who do not meet stated criteria for a given status yet have a comparable severity of illness. Trainees should become familiar with the management of the sensitized patient, including interpretation of panel reactive antibodies, and understand desensitization regimens, including but not limited to plasmapheresis, intravenous immune globulin, rituximab, and bortezomib. Trainees should be exposed to the unique issues involved in considering transplantation for patients with adult congenital heart disease.
184.108.40.206 Acute Postoperative Management
The postoperative management of heart transplant recipients starts with donor evaluation and organ procurement. Trainees should become familiar with the logistics of these steps and gain experience interpreting virtual, prospective, and retrospective cross-matches; determining the need for induction therapy; and managing initial post-transplant immunosuppression and infection prophylaxis.
220.127.116.11 Postoperative Complications
Trainees should become familiar with early postoperative hemodynamics and be able to direct subsequent testing to distinguish such complications as primary graft dysfunction, delayed hyperacute rejection, right heart failure related to PH, and cardiac tamponade. They should become competent as part of a multidisciplinary team in caring for patients requiring temporary mechanical support such as extracorporeal membrane oxygenation. Trainees should develop the skills to manage potential donor-derived infections and malignancies, including informing patients and families of these events, and appropriately consult specialists for further evaluation and management. Trainees should be able to manage other common complications in the early postoperative setting, including early rejection, bradyarrhythmias and tachyarrhythmias, thromboembolism, delirium, and infections.
18.104.22.168 Inpatient Heart Transplant Management Following the Index Admission
Heart transplant patients may be readmitted months or years after transplantation for cardiac or noncardiac problems, such as acute cellular or antibody-mediated rejection, graft failure, transplant vasculopathy, infections, or malignancy. Trainees will be exposed to heart transplant recipients with these complications and should acquire the skills to direct the care of such patients. Trainees should collaborate with cardiac pathologists interpreting biopsies, interventional cardiologists considering percutaneous intervention, and infectious disease specialists treating opportunistic infections (14). Given that the side effects and toxicities of immunosuppression affect many organ systems, the AHFTC trainee will consult with numerous other specialists as well. It is particularly important for trainees to learn the extracardiac toxicities of immunosuppression, such as the neurotoxicity and nephrotoxicity of calcineurin inhibitors, pulmonary toxicity of proliferation signal inhibitors, and gastrointestinal toxicity of mycophenolate mofetil, as patients will likely present symptoms of these conditions initially to the AHFTC specialist (15).
The major goal of outpatient management of a heart transplant recipient is to maximize benefit and minimize toxicity of immunosuppression. Level III trainees should become familiar with strategies to individualize immunosuppression based on the patient’s risk of rejection and infection, as guided by a history of rejection or infection, medication tolerance, antibody sensitization, compliance, presence of transplant vasculopathy, malignancy, peripheral blood gene-expression profiling, and results of T-cell immune function assays. They should learn the role of standard triple-drug immunosuppression with a calcineurin inhibitor, an antimetabolite (most commonly mycophenolate mofetil), and corticosteroids, and know when to consider proliferation signal inhibitors sirolimus or everolimus. Trainees should become familiar with methodologies for rejection surveillance and adjunctive immunotherapies for patients with recurrent rejection.
22.214.171.124 Chronic Complications
Chronic immunosuppression places patients at risk of hypertension, obesity, drug-drug interactions, renal dysfunction, gout, diabetes, dyslipidemia, osteoporosis, infections, malignancy, and other disorders. Thus, trainees should learn appropriate screening and prevention strategies, including immunization, and develop the skills to manage complications in conjunction with other providers. Long-term care of heart transplant recipients includes screening for and management of transplant vasculopathy. Trainees should learn the appropriate triage to revascularization, retransplantation, or end-of-life management.
4.7 Shared Decision Making and Palliative Care
According to the ACCF/AHA Guideline for the Management of Heart Failure, “palliative and supportive care is effective for patients with symptomatic heart failure to improve quality of life” (7). Furthermore, given the acuity of illness to which patients with heart failure are prone, trainees require advanced communication skills to care for critically ill patients and those with complications following LVAD implantation or cardiac transplantation. Trainees should incorporate palliative care throughout the spectrum of illness and know when to consult palliative care specialists. Discussions focused on shared decision making provide patients, families, and providers opportunities to work together to make decisions about care and choose treatment options that are aligned with the patient's values, goals, and preferences (16). For example, trainees should acquire experience re-evaluating and revising the medical regimen and modify device-based therapy as goals of care change toward the end of life.
5 Evaluation of Proficiency
Evaluation tools in AHFTC training include direct observation by instructors, case logbooks, conference and case presentations, multisource evaluations, trainee portfolio/curriculum vitae, in-training examination, and simulation. Self-assessment programs are available through the ACC and Heart Failure Society of America. Program directors and trainees are encouraged to incorporate these resources into the course of training. Following completion of AHFTC training, trainees will be eligible to take the ABIM Board Certification Examination in AHFTC.
Judgement, case management, and bedside and procedural skills must be evaluated regularly in every trainee. Quality of care and follow-up; reliability; judgement or 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–compliant electronic database or logbook that meets ACGME reporting standards and summarizes pertinent clinical information (number of cases, diagnoses, disease severity, outcomes, and disposition for each encounter).
Under the guidance of the program director, faculty should verify and document each trainee’s experiences, assess performance, and confirm satisfactory achievement. The program director is responsible for confirming experience and competence and 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.
Presidents and Staff
American College of Cardiology
Richard A. Chazal, MD, FACC, President
Shalom Jacobovitz, Chief Executive Officer
William J. Oetgen, MD, MBA, FACC, Executive Vice President, Science, Education, Quality, and Publishing
Dawn R. Phoubandith, MSW, Director, Competency Management
Kimberly Kooi, MHA, Education Design Associate
Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing
American Heart Association
Steven Houser, PhD, FAHA, President
Nancy Brown, Chief Executive Officer
Rose Marie Robertson, MD, FAHA, Chief Science and Medicine Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations
Heart Failure Society of America
Mandeep R. Mehra, MD, FHFSA, President
Michele Blair, Chief Executive Officer
International Society for Heart & Lung Transplantation
Maryl R. Johnson, MD, President
Amanda W. Rowe, Executive Director
American College of Physicians
Nitin S. Damle, MD, MS, MACP, President
Darilyn V. Moyer, MD, FACP, Executive Vice President, Chief Executive Officer
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology
Appendix 3 Abbreviation List
ABIM = American Board of Internal Medicine
ACC = American College of Cardiology
ACGME = Accreditation Council for Graduate Medical Education
AHA = American Heart Association
AHFTC = advanced heart failure and transplant cardiology
COCATS = Core Cardiovascular Training Statement
LVAD = left ventricular assist device
MCS = mechanical circulatory support
PH = pulmonary hypertension
RVF = right ventricular failure
RWI = relationships with industry
↵∗ Official International Society for Heart & Lung Transplantation Representative.
↵† Official Heart Failure Society of America Representative.
↵‡ Official American College of Physicians Representative.
↵§ Official American Heart Association Representative.
The document was approved by the American College of Cardiology Lifelong Learning Oversight Committee, the American Heart Association Science Advisory and Coordinating Committee, the Heart Failure Society of America Board of Trustees, the International Society for Heart & Lung Transplantation Board of Trustees, and the American College of Physicians Board of Regents in February 2017, and by the American Heart Association Executive Committee in March 2017. For the purpose of transparency, disclosure information for the ACC Lifelong Learning Oversight Committee, the approval body of the convening organization of this document, is available online.
The American College of Cardiology requests that this document be cited as follows: Jessup M, Drazner MH, Book W, Cleveland JC Jr, Dauber I, Farkas S, Ginwalla M, Katz JN, Kirkwood P, Kittleson MM, Marine JE, Mather P, Morris AA, Polk DM, Sakr A, Schlendorf KH, Vorovich EE. 2017 ACC/AHA/HFSA/ISHLT/ACP advanced training statement on advanced heart failure and transplant cardiology (revision of the ACCF/AHA/ACP/HFSA/ISHLT 2010 clinical competence statement on management of patients with advanced heart failure and cardiac transplant): a report of the ACC Competency Management Committee. J Am Coll Cardiol 2017;69:2977–3001.
This article has been copublished in Circulation: Heart Failure and the Journal of Cardiac Failure.
Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), American Heart Association (http://professional.heart.org), Heart Failure Society of America (www.hfsa.org), International Society for Heart & Lung Transplantation (www.ishlt.org), and American College of Physicians (www.acponline.org). For copies of this document, please contact Elsevier Reprint Department, fax (212) 633-3820 or e-mail .
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- Table of Contents
- 1 Introduction
- 2 General Standards
- 3 Training Components
- 4 Training Requirements
- 5 Evaluation of Proficiency
- Presidents and Staff
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology
- Appendix 2 Peer Reviewer Information—2017 ACC/AHA/HFSA/ISHLT/ACP Advanced Training Statement on Advanced Heart Failure and Transplant Cardiology
- Appendix 3 Abbreviation List