HRS Policy Statement: Clinical Cardiac Electrophysiology Fellowship Curriculum: Update 2011
Article Outline
- Introduction
- 1. Normal physiology
- 2. Genetic basis of arrhythmia
- 3. Diagnosis of arrhythmia
- 4. Treatment of arrhythmia
- 5. Atrial fibrillation and flutter
- 6. Ablation of VT
- 7. Pacemakers (include indications)
- 8. ICD and CRT
- 9. Special conditions
- 10. Insight on ABIM
- References
- Copyright
Introduction
A fellowship curriculum is important in the training of a clinical cardiac electrophysiologist. A clinical cardiac electrophysiology curriculum was first published in 2001 and was the basis for education in many fellowship programs.1 Over the last 10 years cardiac electrophysiology has continued to grow, evolve, and mature so that an update is currently needed. This update is focused on what a practicing electrophysiologist will need in the care of patient. It is not meant to be a mandatory education requirement or to supplant American Board of Internal Medicine (ABIM) or Accreditation Council for Graduate Medical Education (ACGME) requirements. Each section was written by one of the authors, but all authors have reviewed the entire document.
1. Normal physiology
Fellows should possess an understanding of the basic anatomic, cellular and molecular mechanisms of electrophysiology as they pertain to normal physiology. These concepts include the cellular and molecular bases for electrical function of the heart under normal and pathophysiologic conditions, anatomic relationships within the heart, the mechanisms responsible for the development of arrhythmias, and the actions of antiarrhythmic drugs.
2. Genetic basis of arrhythmia
The heritable arrhythmia syndromes, also known collectively as the cardiac channelopathies, represent an exciting and expanding discipline for electrophysiologists.21 Since heart rhythm specialists are typically the primary caretakers for patients with heritable arrhythmia syndromes and their families, the fellow needs to be familiar with the following:
3. Diagnosis of arrhythmia
3.1. Surface ECG and ambulatory monitoringClinical Cardiac Electrophysiology Fellows should meet minimum competency requirements of Cardiovascular Disease fellowship training for electrocardiogram (ECG) interpretation as outlined by the American College of Cardiology Task Force. Fellows are expected to be fully familiar with the indications and performance of a variety of noninvasive ECG tests.
Electrophysiology fellows should be able to list the indications for invasive electrophysiologic studies; perform and interpret a comprehensive electrophysiologic study; create and interpret an electroanatomic endocardial activation map; indicate the sensitivity and specificity of these findings; integrate these findings into the clinical care of the patient, use the information to formulate an ablation strategy when indicated.
Electrophysiology trainees should understand principles of laboratory safety, with regard to maximizing protection of patients, operators, and laboratory staff. Emphasis should be placed on educating trainees in the use and effects of diagnostic radiation. Other categories of laboratory safety include proper use of electrosurgical instruments, and prevention of transmissible diseases.
4. Treatment of arrhythmia
4.1. Basic pharmacokinetics and pharmacodynamicsPharmacokinetics and pharmacodynamics are essential concepts in understanding therapeutic drug delivery. Although drugs are less commonly used clinically as a first-line therapy for ventricular arrhythmias, they frequently are utilized as adjunctive therapy. In addition, antiarrhythmic agents are frequently used for management of atrial fibrillation.
Use dependence and reverse use dependence
It is useful for fellows to understand the scientific basis of lesion formation during catheter ablation. One should know the factors that affect the successful application of an ablative lesion and learn how to modify those factors to yield safe and effective catheter ablations.
4.2.1. Biophysics of ablation
4.2.2. Pathophysiology of ablation
4.2.3. Technologies to create therapeutic ablative lesions
4.2.4. Adjunctive technologies to facilitate catheter ablation
Electrophysiology trainees should be aware of cardiac imaging modalities that aid diagnosis of arrhythmia, as well as invasive management.63, 64 The relevant imaging may be done prior to an invasive procedure (ablation or device implant), online monitoring during the procedure for complication and catheter guidance, as well as risk stratification and selection of the appropriate procedure.
4.3.1. Intracardiac ultrasound examination65, 66, 67
4.3.2. Computerized tomography (CT) for heart and pulmonary veins68
4.3.3. Magnetic resonance imaging69, 70, 71
4.3.4. Imaging to map electrical activation
4.3.5. Ancillary imaging for invasive electrophysiology therapy
Clinical electrophysiology fellows should understand which patients would be expected to benefit from radiofrequency ablation of SVT. They should be confident in the laboratory differential diagnosis of SVT and the techniques required for ablation. They should have experience in the use of three-dimensional mapping systems, techniques for retrograde and transseptal access, and should understand the underlying anatomy sufficiently to help to avoid complications.
5. Atrial fibrillation and flutter
Heart rate control and rhythm control with drugs remain the mainstay of therapy of atrial fibrillation, however; it has become clear that when drug therapy fails to control symptoms, this goal can be accomplished by ablation. Accumulating evidence that restoration of sinus rhythm by ablation improves symptoms, cardiac function and exercise capacity in selected groups of patients has led to large-scale morbidity and mortality trials, which are ongoing. Even if these trials are ultimately negative, the major symptomatic benefits of restoration of sinus rhythm by ablation suggests that competence endocardial ablation for atrial fibrillation and atrial flutter has become a requirement for graduating EP fellows.
Anticoagulation with vitamin K antagonists (i.e., warfarin) remains the mainstay of stroke prevention, although left atrial occlusion devices are likely to become clinically available in the lifetime of this document. Most significantly, perhaps, alternatives to anticoagulation with vitamin K antagonists have been developed, and a prototypical direct thrombin inhibitor, dabigatran, is now approved in the US. Other direct thrombin inhibitors and direct factor Xa antagonists are undergoing clinical trials and will likely be clinically available soon.
5.1. Atrial fibrillation6. Ablation of VT
Fellows should recognize the indications, patient selection, risks and anticipated benefits of catheter ablation for ventricular arrhythmias associated with or without structural heart disease. It is reasonable to expect a cure for the majority of patients with truly idiopathic VT, whereas catheter ablation usually is palliative in organic heart disease, especially in advanced ischemic and non-ischemic heart disease. A recent consensus document summarizes characteristics of ventricular arrhythmias as well as patient selection for ablation, and ablation results.119
7. Pacemakers (include indications)
The principles and practice of cardiac pacing are core competencies for a cardiac electrophysiologist.129 Fellows should fully understand the indications for temporary and permanent pacing, their limitations, and how to combine them with other therapies. Fellows should be technically proficient in placing, programming and troubleshooting such devices. Knowledge of the biophysics of pacing, the bioengineering of pacemakers and how they may be influenced by external devices and biophysical sources is also important.
8. ICD and CRT
A training program in clinical cardiac electrophysiology should include sufficient technical and clinical instruction in advanced device management to allow the fellow to provide highly competent clinical assessment, patient selection, device implantation, and follow-up of eligible patients. This applies to single and dual chamber ICDs, and CRT-D and CRT-P systems. This includes the direct management of the patient with respect to cardiac arrhythmias, the overall management of the patient including heart failure and the implanted system management with respect to performance.
9. Special conditions
9.1. SyncopeThe evaluation and management of patients with unexplained syncope is an important component of electrophysiology fellowship training. The fellow must understand the guidelines for hospitalization,155, 156 develop a strategy to identify a cause of syncope,155, 156, 157, 158, 159 and effectively risk stratify patients.155, 157, 160, 161, 162 Prolonged electrocardiographic (ECG) monitoring is an important diagnostic tool in some patients.159 Patients with structural heart disease are increasingly being treated with an implantable cardioverter-defibrillator (ICD); however, mortality remains high in these patients.155, 161, 162
It is important for electrophysiology fellows to recognize the magnitude and different mechanisms that underlie sudden cardiac death (SCD). Fellows should be cognizant of the different precipitants of arrhythmias; comprehend evidence-based strategies for managing patients who are survivors of SCD; understand the pharmacological and non-pharmacological approaches of managing patients at risk for SCD; and grasp the different risk stratification strategies to predict and prevent SCD. Fellows should be up to date with all the completed clinical trials in this area while being aware of the most important studies nearing completion.
10. Insight on ABIM
When a constituent body of the American Board of Medical Specialties (ABMS), such as the American Board of Internal Medicine, decides that a specialty area has matured sufficiently, the Board establishes an examination in that field and prescribes the body of knowledge that will be covered by the examination. In a somewhat analogous fashion, the Accreditation Council for Graduate Medical Education (ACGME) then directs one of its Residency Review Committees (RRC) to establish the standards to determine whether a given hospital or other learning center can provide the necessary resources to provide the prescribed education. The ACGME provides a learning philosophy (presently the “six competencies”) and accreditation of teaching sites is based on whether such sites, including staff, faculty, and trainees, are performing satisfactorily with respect to the six competencies. The ACGME makes these determinations based on standardized self-study forms (Program Information Forms) from each site, and an exhaustive site visit that is carried out at intervals that depend largely on the overall track record of a given site, and how well the site has responded to citations from previous reviews. All of this takes a lively interaction among many interested parties, including professional societies such as the Heart Rhythm Society and the American College of Cardiology, the “House of Medicine” (American Medical Association), hospitals (American Hospital Association), and primary specialty groups (e.g., American College of Physicians-ACP). All of these are advisory.
The ABIM is definitive when it comes to the qualifications of an individual to sit for the boards. The ACGME through its RRCs is definitive when it comes to certifying a site as capable of providing the necessary learning experience. Many cardiology fellows and CCEP fellows believe that the ACC's Core Cardiology Training (COCATS) criteria are definitive; although influential, they are not definitive. The Residency Review Committee's criteria are definitive and differ somewhat from both the current ABIM and COCATS criteria.
At the time of first approval, the knowledge and experience base needed to sit for the board exams are determined by the ABIM. Thereafter, it is an iterative process. At the present time, the ABIM is funneling its energies into changing over from the concept of a test every 10 years to an ongoing maintenance of certification process that emphasizes lifelong learning. Thus, the RRC's proposed program requirements for clinical cardiac electrophysiology have more detailed and stricter electrophysiology procedure requirements than those of the ABIM. However, this does not pose a problem because one must be a graduate of an ACGME-approved program to sit for the ABIM boards.
ABIM PROCESS: The main component is the educational philosophy of lifelong learning, which is part of the evolution from certification to recertification to maintenance of certification. For each of the areas for which there is a board examination or “added qualifications” exam, a committee of experts is convened. This committee also contains educational philosophers and psychometricians. Together, they develop an examination designed to test the relevant body of knowledge in as fair and scientific a method as possible. The physician experts are usually well known in their respective field and they bring with them information from their professional bodies, the literature, and their own experience.
The ACGME has RRCs for the broad specialties. For example, there is an RRC for internal medicine that certifies the training programs for the core internal medicine training programs, all the subspecialties (in this case cardiology) and all the “sub-subs,” e.g., CCEP. The ACGME provides broad umbrella requirements that extend to all major specialties (Surgery, Pediatrics, Internal Medicine, etc.), and the respective RRCs use these broad guidelines to develop the specific and detailed guidelines for each training program. Thus, program directors in CCEP need to look at the “common program requirements” and the respective program requirements for Internal Medicine and Cardiology, as well as those for CCEP. The subspecialties do not exist in a vacuum, but must be in an overall milieu, which includes a core internal medicine program, and several specialties with close communication from the various program directors. For each program, the RRC determines many of the details, such as minimum faculty, procedure volumes, conferences, continuity clinic, etc. Again, following the ACGME philosophy, the RRCs are charged with ensuring that the programs and the learners are all imbued with the concept of the six competencies. Indeed, outcomes are judged largely by assessment of how well the six competencies have been achieved by the residents and fellows at the time of completion of their program.
Input through the RRCs comes from many sources. The RRC leads many patterns each year, with agendas that include evaluation of programs based on self-study and site visits and other meetings at which strategy, tactics, and updates are the primary items on the agenda. The internal medicine RRC is comprised of five generalists and two physicians from each of the specialties. At the present time, the author represents cardiology broadly and electrophysiology in particular. There is another nonelectrophysiology cardiologist on the committee. A subcommittee of the RRC establishes the program requirements for each of the subspecialties and sub-subs. Each RRC meeting is also attended by staff, some of whom are specifically assigned to the internal medicine RRC, and by others who represent the general ACGME. Further, there are ex official members, nonvoting, representing the ABIM, American Medical Association, and American College of Physicians.
Input for determination of requirements for internal medicine and all its subs and sub-subs is reported to a subcommittee of the RRC, which establishes proposed requirements. Input can come from any source, ranging from the literature to special advisory groups such as co-cats, the ABIM, etc. The RRC is in the position of having authority over all internal medicine training programs in the United States. It, therefore, recognizes the variation that can exist; thus, some requirements may differ from those proposed by professional organizations. In some cases, promulgation of such “ideal” requirements would endanger the certification of a number of otherwise strong training programs. The reader of program requirements must also be aware of the RRC “coded language,” in which “suggests” means “it would be a very good idea,” “should” means “you really ought to do it or tell us why,” and “must” means “just do it.”
SUMMARY: The ABIM is definitive for the individual, and the ACGME/RRC is definitive for programs (Figure 1). There is some overlap in a Venn diagram fashion between the areas covered by these two definitive organizations. Other bodies, organizations, or ideas are advisory only.
Figure 1.
Trainee learning experience. Interaction between the trainee, training site, and the various organizations such as COCATS (ACC’s Core Cardiology Training), ABMS (American Board of Medical Specialties), ABIM (American Board of Internal Medicine), AAMC (Association of American Medical Colleges), AMA (American Medical Association), ACGME (Accreditation Council for Graduate Medical Education), APDIM (Association of Program Directors in Internal Medicine), RRC (Residency Review Committees).
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Endorsed by the Heart Rhythm Society in May 2011. Correspondence and reprint requests: Sonja Olson, Heart Rhythm Society, 1400 K Street NW, Suite 500, Washington, DC, 20005. Email: solson@hrsonline.org
PII: S1547-5271(11)00680-1
doi:10.1016/j.hrthm.2011.06.008
© 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
