Author + information
- Published online March 9, 2020.
- Clyde W. Yancy, MD, MSc, MACC, FHFSA, Chair, Writing Committee,
- Mark H. Drazner, MD, MSc, FACC, FHFSA, Vice Chair, Writing Committee,
- Samuel Tristram Coffin, MD, FACC, Writing Committee Member,
- William Cornwell III, MD, Writing Committee Member,
- Shashank Desai, MD, MBA, FACC, Writing Committee Member∗,
- John P. Erwin III, MD, FACC, Writing Committee Member,
- Mahazarin Ginwalla, MD, MS, FACC, Writing Committee Member†,
- Karol S. Harshaw-Ellis, ACNP-BC, DNP, FHFSA, Writing Committee Member∗,
- Tamara Horwich, MD, MS, FACC, Writing Committee Member,
- Michelle Kittleson, MD, PhD, FACC, Writing Committee Member,
- Anuradha Lala, MD, FACC, Writing Committee Member,
- Sabra C. Lewsey, MD, MPH, Writing Committee Member,
- Joseph E. Marine, MD, FACC, Writing Committee Member,
- Cindy M. Martin, MD, Writing Committee Member,
- Karen Meehan, ACNS-BC, MSN, CVRN, Writing Committee Member†,
- David A. Morrow, MD, MPH, FACC, Writing Committee Member,
- Kelly Schlendorf, MD, MHS, Writing Committee Member∗,
- Jason W. Smith, MD, Writing Committee Member† and
- Gerin R. Stevens, MD, PhD, FACC, FHFSA, Writing Committee Member
- ACC/HFSA/ISHLT Lifelong Learning Statement
- advanced heart failure
- heart transplantation
- lifelong learning
- mechanical circulatory support
- professional competencies
- pulmonary hypertension
ACC Competency Management Committee
James A. Arrighi, MD, FACC, Chair
Lisa A. Mendes, MD, FACC, Co-Chair
Jesse E. Adams III, MD, FACC‡
John E. Brush, Jr, MD, FACC‡
G. William Dec, Jr, MD, FACC
Ali Denktas, MD, FACC
Susan Fernandes, LPD, PA-C
Rosario Freeman, MD, MS, FACC‡
Sanjeev A. Francis, MD, FACC
Rebecca T. Hahn, MD, FACC
Jonathan L. Halperin, MD, FACC§
Susan D. Housholder-Hughes, DNP, ACNS-BC, ANP-BC, FACC
Sadiya S. Khan, MD, FACC
Kyle Klarich, MD, FACC
C. Huie Lin, MD, PhD, FACC
Joseph E. Marine, MD, FACC
John A. McPherson, MD, FACC‡
Khusrow Niazi, MBBS, FACC
Thomas Ryan, MD, FACC
Michael A. Solomon, MD, FACC
Robert L. Spicer, MD, FACC
Marty Tam, MD‡
Andrew Wang, MD, FACC, FAHA
Gaby Weissman, MD, FACC
Howard H. Weitz, MD, MACP, FACC
Eric S. Williams, MD, MACC‖
Table of Contents
1. Introduction 1214
1.1. Document Development Process 1214
1.1.1. Writing Committee Organization 1214
1.1.2. Document Development and Approval 1215
1.2. Background and Scope 1215
Table 1. Entrustable Professional Activities for Specialists in Cardiovascular Disease 1215
1.2.1. AHFTC Lifelong Learning Competencies 1215
1.2.2. Research and Scholarly Activity 1216
Table 2. ACGME Core Competencies 1216
2. Clinical Competencies 1216
2.1. Distinction Between Competencies Expected of All AHFTC Specialists and Those Required Based on the Focus of Practice 1216
Table 3. Lifelong Learning Competencies for AHFTC Specialists 1217
Table 4. Common Professional Behavior Competencies Relevant to All Clinical Cardiovascular Disease Specialists 1224
3. Leadership and Administrative Competencies 1216
4. Maintenance of Competence and Assessment Tools 1225
Author Relationships With Industry and Other Entities (Relevant) 1227
Peer Reviewer Information 1229
Since the publication of its first Core Cardiovascular Training Statement (COCATS) in 1995 (1), the American College of Cardiology (ACC) has defined the knowledge, experiences, skills, and behaviors expected of clinical cardiologists. Subsequent revisions have moved toward competency-based training based on 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). The ACC has taken a similar approach to describe the aligned general cardiology lifelong learning competencies that practicing cardiologists are expected to maintain. Many hospital systems now use the 6-domain structure as part of medical staff privileging, peer-review, and professional competence assessments.
Whereas COCATS and the associated Lifelong Learning Competencies for General Cardiologists (2) focus on general clinical cardiology, ACC Advanced Training Statements and associated Lifelong Learning Statements define selected competencies beyond those expected of all cardiologists that typically require training beyond a standard 3-year cardiovascular disease fellowship. This includes, but is not limited to, those disciplines for which there is an ABIM subspecialty certification. The Advanced Training Statements describe key experiences and outcomes necessary to acquire skills in a defined subspecialty area of cardiology in a structured training program. These are supplemented by 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 outcome-based evaluation system. Although specific areas of training may require a minimum number of procedures or duration of training to ensure adequate exposure to the range of clinical disorders, the objective assessment of proficiency and outcomes demonstrates the achievement of competency. Evaluation tools include examinations, direct observation, procedure logbooks, simulation, conference presentations, and multisource (360°) evaluations. For practicing physicians, these tools also include professional society registry or hospital quality data, peer-review processes, and patient satisfaction surveys. A second feature of competency-based training is recognition that learners gain competency at different rates. For multiyear training programs, assessment of representative curricular milestones during training can identify learners or areas that require additional focused attention.
The recommendations in ACC cardiovascular Training and Lifelong Learning Statements are based on available evidence and, where evidence is lacking, reflect consensus expert opinion. The writing committees are broad-based and typically include early-, mid-, and later-career specialists; general cardiology and subspecialty training directors; practicing cardiologists; people working in institutions of various sizes and in diverse practice settings across the United States; and nonphysician members of the cardiovascular care team. All documents undergo a rigorous process of peer review and public comment. Recommendations are intended to guide the assessment of competence of cardiovascular care providers beginning independent practice as well as those undergoing periodic review to ensure that competence is maintained.
This Lifelong Learning Statement addresses the competencies required of advanced heart failure and transplant cardiology (AHFTC) specialists and complements formal AHFTC fellowship training. The Statement delineates the core competencies reasonably expected of all individuals trained at this level. Furthermore, the Statement identifies additional, selected competencies of AHFTC specialists, the majority of which would be expected of all AHFTC specialists at completion of their formal advanced training, but some of which may no longer be applicable to certain AHFTC specialists later in their career. We recognize that some AHFTC specialists who care for patient populations who have not undergone implantation of durable left ventricular assist devices or cardiac transplantation exemplify this situation. This Statement also provides examples of appropriate measures for assessing competence in the context of lifelong learning.
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 resulting from relationships with industry (RWI) or other entities of members of the Writing Committee or peer reviewers of the document, each individual was required to disclose all current healthcare-related relationships as well as those existing 12 months before initiation of the writing effort. The ACC Competency Management Committee reviewed these disclosures to identify products (currently 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 had no relevant RWI. Authors with relevant RWI were not permitted to 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. Employment information and affiliations of the peer reviewers are shown in Appendix 2. There are no RWI restrictions for participation in peer review, in the interest of encouraging comments from a variety of constituencies to ensure that broad viewpoints inform final document content. Reviewers are required, however, to disclose all healthcare-related RWI and other entities, 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.
James A. Arrighi, MD, FACC
Chair, ACC Competency Management Committee
Lisa A. Mendes, MD, FACC
Co-Chair, ACC Competency Management Committee
1.1 Document Development Process
1.1.1 Writing Committee Organization
The writing committee consisted of 19 members from across the United States representing the ACC, the Heart Failure Society of America (HFSA), and the International Society for Heart & Lung Transplantation (ISHLT), identified because they fit into ≥1 of the following roles/categories: AHFTC training program directors; experts at early, mid-, and later-career stages; 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, cardiac resynchronization therapy, and pulmonary arterial hypertension; specialists in cardiothoracic surgery, critical care cardiology, electrophysiology, and adult congenital heart disease; members who have worked with ABIM; 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; AHFTC fellows-in-training; ventricular assist device transplant coordinators; and advanced practice nurses. The 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 chairs, Competency Management Committee chairs, and Competency Management Committee liaison convened to plan the writing effort, select authors on the basis of the criteria specified in Section 1.1.1, and draft the preliminary competency table for writing committee review. Authors of the published 2017 AHFTC Advanced Training Statement were invited to provide initial feedback on the competency table prior to the launch of the new writing effort. The writing committee convened by conference call and e-mail to finalize the document outline, develop the initial draft, revise the draft on the basis of committee feedback, and ultimately approve the document for external peer review.
The document was reviewed by 9 official representatives from the ACC, HFSA, and ISHLT, as well as by 21 additional content reviewers (see Appendix 2). It was simultaneously posted for public comment on the website of the American College of Cardiology from February 21, 2019, to March 25, 2019. A total of 210 comments were submitted on the document. 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 governing bodies of the ACC, HFSA, and ISHLT 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
In 2010, the ACC began an ambitious initiative to delineate: 1) the core clinical competencies essential for trainees to attain during a 3-year cardiovascular fellowship (COCATS 4) (3); and 2) the aligned competencies that patients and accrediting bodies can reasonably expect clinical cardiologists in practice to acquire, maintain, or enhance through lifelong learning throughout their career (2). Key features of this outcomes-based curriculum include the 6-domain structure promulgated by the ACGME and the American Board of Medical Specialties and endorsed by the ABIM. The cardiovascular competencies provide a structure for the ACC learning pathways and underpin all ACC educational activities.
The lifelong learning competencies for general cardiologists were published in 2016 and incorporated the new curricular competency format aligned with the COCATS 4 training milestones (2). Although the COCATS 4 and lifelong learning competencies are similar, they are distinct, reflecting the impact of practice focus, experience, and additional education and training on expectations of competency. Similarly, an advanced training statement on AHFTC, germane to fellowship training, was published in 2017 (4), whereas this current document now represents the corresponding lifelong learning competencies for AHFTC specialists in practice based on their specific training, experience, and practice focus. The aggregated lifelong learning competencies collectively underlie the Entrustable Professional Activities that patients and the public can reasonably expect all competent clinical cardiologists, including AHFTC specialists, to be able to perform (Table 1).
1.2.1 AHFTC Lifelong Learning Competencies
The lifelong learning competencies for AHFTC are organized using the 6 domains promulgated by ACGME and the American Board of Medical Specialties and endorsed by the ABIM (Table 2) and are outlined in Section 1. Section 2 focuses on clinical competencies. Section 3 focuses on leadership and administrative competencies that pertain to all cardiovascular specialists, including AHFTC specialists.
1.2.2 Research and Scholarly Activity
Scholarly activity and clinical research are important in lifelong learning and professional competency. All physicians should have the skills to assess new research findings and appropriately incorporate new diagnostic and treatment modalities in patient care. In addition, physicians should utilize a scholarly approach to evaluate evidence, address clinical questions, and enhance outcomes through literature review, including at the point of care. They should use a systematic approach to assess high-quality evidence from a variety of sources to apply a patient-centered approach to optimizing care and outcomes across all settings. Physicians should maintain and enhance knowledge through regular reading of peer-reviewed journals and other sources of reliable information, and through attending scientific meetings and professional congresses. Referral of patients for participation in well-designed clinical trials is encouraged for both academic and nonacademic cardiologists.
2 Clinical Competencies
Table 3 encompasses both the medical knowledge competencies and patient care and procedural skill competencies specifically related to AHFTC. Table 4 specifies a common set of professional behavior competencies that fall under the ACGME competency domains of systems-based practice, practice-based learning and improvement, interpersonal and communication skills, and professionalism. Although these competencies are relevant to all clinical cardiovascular disease specialists, they should be interpreted within the context of AHFTC practice.
2.1 Distinction Between Competencies Expected of All AHFTC Specialists and Those Required Based on the Focus of Practice
Table 3 distinguishes competency components expected of all AHFTC specialists (left column) from those expected of selected AHFTC specialists on the basis of background, specialized knowledge, skills, experience, and practice focus (right column). This distinction is particularly relevant to the patient care competencies and recognizes diversity in the focus of practice of AHFTC specialists. Some physicians may specialize in a particular aspect of AHFTC, such as mechanical circulatory support or cardiac transplantation, while others may adopt a practice focused on patients with chronic heart failure with a lesser need for advanced heart failure interventions. These distinctions may be magnified later in specialists’ careers with divergence of practice focus and can be contrasted with the broader range of core competencies representing the breadth of the AHFTC field that is expected of an AHFTC trainee upon completion of fellowship, as outlined in the prior Advanced Training Statement. However, if an AHFTC specialist cares for patients with left ventricular assist devices or those who have undergone heart transplantation, it would be expected that they maintain all such relevant competencies.
3 Leadership and Administrative Competencies
In addition to clinical competency, AHFTC specialists are expected to function effectively as leaders in allied efforts to ensure high-quality care and promote individual and population health. These skills are particularly necessary as a greater reliance on team management begins to define the care of patients with heart failure. Some of these activities and attributes fall outside the realm of clinical knowledge and skill and instead involve administrative roles in clinical practice, hospitals, health systems, professional societies, or other organizations. It is important for AHFTC specialists to exercise cultural sensitivity in the critical decision making affecting the quality and duration of life in varied populations affected by heart failure. Specific competencies expected of all general cardiologists and cardiovascular specialists, including those with roles in administrative, managerial, or advocacy positions, are delineated in Table 24 of the 2016 ACC Lifelong Learning Competencies for General Cardiologists (2).
4 Maintenance of Competence and Assessment Tools
Continuing practice of AHFTC requires ongoing maintenance of competency beyond original training. The requirements for training as a specialist in AHFTC are delineated in the 2017 Advanced Training Statement on AHFTC, including the specific competencies required to achieve competence as well as recommendations for minimum procedural volume to demonstrate competence in AHFTC (4). As practitioners continue in their careers beyond initial training, it is recognized that many practice opportunities and challenges will exist. As such, prescribing specific numerical requirements to any particular procedure is problematic, with patterns of practice varying between individuals as well as during the lifelong practice of AHFTC. However, the AHFTC specialist should be familiar with the literature that has associated improved outcomes with adequate procedural volume. Where appropriate, such data could be used to guide local maintenance of expertise in procedural skills.
In addition, there are a number of ways in which AHFTC specialists can maintain competency and expand lifelong learning in the course of practice and assess their own professional needs for education and performance improvement. Objective competence evaluation in the practice setting can be challenging but can be achieved through the use of assessment tools and learning resources that are available for this purpose and applicable to all AHFTC specialists. Activities that can demonstrate competency include:
▪ Successful completion of a dedicated AHFTC training program.
▪ ABIM certification following completion of AHFTC training.
▪ Certification via a maintenance of certification process.
▪ Participation in ongoing continuing medical education programs.
▪ Participation in quality of care measures in hospital databases and national registries (e.g., ACC National Cardiovascular Data Registry), including procedure-specific registries where they apply.
▪ Performance of an adequate annual volume of endomyocardial biopsy and right heart catheterization to maintain skills that demonstrate proficiency as an AHFTC specialist, and where possible, submission of results for open scrutiny in the appropriate national databases.
▪ Obtaining adequate training through coursework, proctoring, and simulation laboratories for new or revamped technologies and procedures.
Importantly, there is a growing subspecialization career focus within AHFTC. Specifically, some practitioners limit the scope of their clinical activity to treating patients with advanced heart failure, including those who undergo implantation of a durable ventricular assist device or cardiac transplantation, while others focus on disease management of patients with less advanced heart failure. Thus, although maintenance of some AHFTC competencies is an expectation for all clinical AHFTC specialists, the maintenance of selected AHFTC competencies and the evaluation tools to assess them can be career focused.
Presidents and Staff
American College of Cardiology
Richard J. Kovacs, MD, FACC, President
Timothy W. Attebery, DSc, MBA, FACHE, Chief Executive Officer
John S. Rumsfeld, MD PhD FACC, Chief Science and Quality Officer
Dawn R. Phoubandith, MSW, Team Leader, Competencies and Educational Gaps
Teresa V. Callahan, Document Production Specialist
Amelia Scholtz, PhD, Publications Manager, Science, Education, Quality, and Publishing
Heart Failure Society of America
Randall C. Starling, MD, MPH, FHFSA, President
John D. Barnes, Chief Executive Officer
Anna Leong, Manager, Publications
The International Society for Heart & Lung Transplantation
Jeffrey Teuteberg, MD, President
Amanda Rowe, Executive Director
Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2020 ACC/HFSA/ISHLT Lifelong Learning Statement for Advanced Heart Failure and Transplant Cardiology Specialists
Appendix 2 Peer Reviewer Information—2020 ACC/HFSA/ISHLT Lifelong Learning Statement for Advanced Heart Failure and Transplant Cardiology Specialists
Appendix 3 Abbreviations
ABIM = American Board of Internal Medicine
ACC = American College of Cardiology
ACGME = Accreditation Council for Graduate Medical Education
AHFTC = Advanced Heart Failure and Transplant Cardiology
COCATS = Core Cardiovascular Training Statement
HFSA = Heart Failure Society of America
ISHLT = International Society for Heart & Lung Transplantation
RWI = relationships with industry
↵∗ Heart Failure Society of America representative.
↵† International Society for Heart & Lung Transplantation representative.
↵‡ Former Competency Management Committee member; member during this writing effort.
↵§ Former Competency Management Committee co-chair; co-chair during this writing effort.
↵‖ Former Competency Management Committee chair; chair during this writing effort.
The document was approved by the American College of Cardiology Lifelong Learning Oversight Committee, the Heart Failure Society of America Board of Trustees, and the International Society for Heart & Lung Transplantation Board of Trustees in October 2019. For the purpose of transparency, disclosure information for the Lifelong Learning Oversight Committee, the approval body of the convening organization of this document, is available at http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/clinical-document-approval.
The American College of Cardiology requests that this document be cited as follows: Yancy CW, Drazner MH, Coffin ST, Cornwell W III, Desai S, Erwin JP III, Ginwalla M, Harshaw-Ellis KS, Horwich T, Kittleson M, Lala A, Lewsey SC, Marine JE, Martin CM, Meehan K, Morrow DA, Schlendorf K, Smith JW, Stevens GR. 2020 ACC/HFSA/ISHLT lifelong learning statement for advanced heart failure and transplant cardiology specialists: a report of the ACC Competency Management Committee. J Am Coll Cardiol 2020;75:1212–30.
This article has been copublished in 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), Heart Failure Society of America (www.hfsa.org), and International Society for Heart & Lung Transplantation (www.ishlt.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail .
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (https://www.elsevier.com/about/our-business/policies/copyright/permissions).
- 2020 American College of Cardiology Foundation, the Heart Failure Society of America, and the International Society for Heart & Lung Transplantation
- Alpert J.S.
- Williams E.S.,
- Halperin J.L.,
- Arrighi J.A.,
- et al.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.,
- et al.
- Jessup M.,
- Drazner M.H.,
- Book W.,
- et al.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.
- ACC Competency Management Committee
- Table of Contents
- 1 Introduction
- 2 Clinical Competencies
- 3 Leadership and Administrative Competencies
- 4 Maintenance of Competence and Assessment Tools
- Presidents and Staff
- Appendix 1 Author Relationships With Industry and Other Entities (Relevant)—2020 ACC/HFSA/ISHLT Lifelong Learning Statement for Advanced Heart Failure and Transplant Cardiology Specialists
- Appendix 2 Peer Reviewer Information—2020 ACC/HFSA/ISHLT Lifelong Learning Statement for Advanced Heart Failure and Transplant Cardiology Specialists
- Appendix 3 Abbreviations