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Journal of the American College of Cardiology Vol. 47, No. 4, 2006© 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00P

ACCF 2006 Update for Training inAdult Cardiovascular Medicine

(Focused Update of the 2002COCATS 2 Training Statement)

A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians

ublished by Elsevier Inc. doi:10.1016/j.jacc.2005.12.025

Task Force on Clinical Competence and Training

AUTHORS (AND SOCIETY REPRESENTATIONS)

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ntroduction/Steering Committee Co-Chairseorge A. Beller, MD, MACCobert O. Bonow, MD, FACCalentin Fuster, MD, PHD, FACC

ask Force 5: Training in Nuclear Cardiologyanuel D. Cerqueira, MD, FACC, Chairaniel S. Berman, MD, FACCarcelo F. Di Carli, MD, FACCeinrich R. Schelbert, MD, PHD, FACC

rans J. Th. Wackers, MD, PHD, FACCim Allan Williams, MD, FACC (American Society

of Nuclear Cardiology Representative)

ask Force 6: Training in Specializedlectrophysiology, Cardiac Pacing, andrrhythmia Managementerald V. Naccarelli, MD, FACC, Chair

amie B. Conti, MD, FACCohn P. DiMarco, MD, PHD, FACCynthia M. Tracy, MD, FACC (Heart Rhythm

Society Representative)

Mark A. Creager, MD, F

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ollege of Cardiology Foundation. Please direct requests to [email protected]

ask Force 12: Training in Advanced Cardiovascularmaging (Cardiovascular Magnetic Resonance [CMR])erald M. Pohost, MD, FACC, Chairaymond J. Kim, MD, FACChristopher M. Kramer, MD, FACCarren J. Manning, MD, FACC (Society forCardiovascular Magnetic Resonance Representative)

ask Force 12: Training in Advanced Cardiovascularmaging (Computed Tomography)

atthew J. Budoff, MD, FACC, FAHA, Chairtephan Achenbach, MD (Society of Cardiovascular

Computed Tomography Representative)ahi Fayad, PHD (Society of Atherosclerosis Imaging and

Prevention Representative)aniel S. Berman, MD, FACCichael Poon, MD, FACCllen J. Taylor, MD, FACC, FAHAarry F. Uretsky, MD, FACC (Society for Cardiovascular

Angiography and Interventions Representative)im Allan Williams, MD, FACC (American Society of

Nuclear Cardiology Representative)

TASK FORCE MEMBERS
ACC, FAHA, Chair
eno Merli, MD, FACPeorge P. Rodgers, MD, FACC, FAHA

ohn D. Rutherford, MD, FACC, FAHA

This document was approved by the American College of Cardiology FoundationWhen citing this document, the American College of Cardiology would appreciate

raining in Adult Cardiovascular Medicine (Focused Update of the 2002 COCATSssociation/American College of Physicians Task Force on Clinical Competence anCopies: This document is available on the American College of Cardiology website

-800-253-4636 or by writing to the American College of Cardiology, Resource CePermissions: Multiple copies, modification, alteration, enhancement, and/or distrib

ynthia M. Tracy, MD, FACCoward H. Weitz, MD, FACC, FACP

of Trustees in January 2006.llowing citation format: Beller GA, Bonow RO, Fuster V. ACCF 2006 Update forining Statement): a report of the American College of Cardiology/American Heartning. J Am Coll Cardiol 2006;47:893–920..acc.org. Single copies of this document may be purchased for $10.00 each by calling111 Old Georgetown Road, Bethesda, Maryland 20814-1699.of this document are not permitted without the express permission of the American
g.
http://www.acc.org

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ntroductioneorge A. Beller, MD, MACC, Co-Chairobert O. Bonow, MD, FACC, Co-Chair

ublished by Elsevier Inc. doi:10.1016/j.jacc.2005.12.026

alentin Fuster, MD, PHD, FACC, Co-Chair

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n 1995, guidelines for training in adult cardiovascularedicine were published as an outgrowth of a consensus

tatement emanating from the Core Cardiology Trainingymposium (COCATS) held at Heart House, Bethesda,aryland, June 27 to 28, 1994 (1). Since publication of the

roceedings of that consensus conference, the termCOCATS” has been used when referring to the Americanollege of Cardiology (ACC) training guidelines for fellow-

hip programs. The first COCATS document was pub-ished in 1995, followed by a revised document published in002 (2).The 2002 revision (2) was accomplished by the formation

f task forces that included representatives from the sub-pecialty societies where appropriate. These task forceseviewed the 1995 COCATS task force reports and madeevisions, additions, and deletions based on data from theiterature and their expert opinion. Major changes were mostften related to maturing of either new subspecialty areas inardiology or the emergence of new technology into acceptedractice. Numbers of procedures to be performed, interpreted,r both were made consistent with volume recommenda-ions found in the ACC/American Heart Association (AHA)ractice guidelines, ACC/AHA/American College of Physi-ians (ACP) clinical competence statements, or other relevantonsensus documents.

In 2005, with further emerging technologies and the needor training, it was deemed necessary to provide additionalevisions to three of the task force reports and introduce aew report on training in cardiac computed tomography.he three task force reports in this document were peer

eviewed by the following ACCF committees: Clinicallectrophysiology Committee (Task Force 6); Cardiovas-

ular Imaging Committee (Task Force 12); and the Cardiacatheterization and Intervention Committee (Task Force2 [CT]), as well as five members of the ACC Board ofovernors. Several organizations also reviewed the docu-ent including the American Society of Nuclear Cardiology

Task Forces 5 and 12 [computed tomography (CT)]),eart Rhythm Society (Task Force 6), Society for Cardio-

ascular Magnetic Resonance (Task Force 12 [magneticesonance]), and the Society for Cardiovascular Angiogra-hy and Interventions, Society of Atherosclerosis Imagingnd Prevention (SAIP), and Society of Cardiovascularomputed Tomography (Task Force 12 [CT]). Organiza-

ional endorsements are noted on each Task Force report.Task Force 5 revised the nuclear cardiology training report,

hich now identifies the need for both didactic learning andlinical application of hybrid systems including single-photon
mission CT/CT and positron emission tomography/CT. The a
T component can be utilized for attenuation correction ofadionuclide uptake as well as for specific stand-alonemaging of coronary calcification for atherosclerosis detec-ion and CT angiography. The latter application presentlymploys a separate 16- or 64-slice CT scanner (see Taskorce 12). The minimal number of months of training forevel 1, Level 2, and Level 3 categories remains at 2, 4, and2 months, respectively. Education in radiation safety re-uires a minimum of 80 h and must be clearly documented.or Level 2 training, a total of 300 cases should be

nterpreted under preceptor supervision from direct patienttudies. In this revised task force report, guidelines for theadiation safety curriculum that meets Nuclear Regulatoryommission requirements or the equivalent agreement state

equirements are outlined in detail. General and specializedraining in positron emission tomography imaging arelearly described in this section, as is training with hybridT imaging technology, including the physics of hybrid

ystems, CT attenuation correction, principles and applica-ion of CT coronary calcium assessment, and principles andpplication of CT coronary angiography.

Task Force 6 revisions on training in specialized electro-hysiology, cardiac pacing, and arrhythmia management arencluded in this interim COCATS report. The field oflinical cardiac electrophysiology has experienced majordvances in recent years, and such progress is now reflectedn these updated training recommendations. The guidelines forse of implantable pacemakers and implantable cardioverter-efibrillators (ICDs) have significantly expanded since 2002, asave interventional ablation techniques as for atrial fibrillation.The expanded indications for these devices or technology

ave necessitated concomitant revisions for training of physi-ians in the subspecialty of electrophysiology, which areeflected in this revised task force report. The minimumumber of months for Level 1, Level 2, and Level 3 training

n cardiac electrophysiology are 2, 6, and 12 months ofraining, with the latter requiring a full fourth year ofellowship. Level 2 training now also emphasizes acquisitionf skills and experience for managing patients with biven-ricular pacing and ICD systems. In addition to completingevel 1 and Level 2 training, Level 3 training requires that

rainees perform at least 150 electrophysiologic proceduresnd be a primary operator and analyze 100 to 150 diagnostictudies, of which 50 to 75 involve patients with supraven-ricular arrhythmias. Training guidelines for gaining addi-ional expertise in atrial fibrillation ablation are expanded tonclude exposure to imaging technologies used to definentracardiac anatomy. A detailed description of how Level 2
nd Level 3 trainees can acquire training in the surgical

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895JACC Vol. 47, No. 4, 2006 Beller et al.February 21, 2006:894–7 Introduction

spects of device implantation are provided, as are guide-ines for becoming proficient in implantation and follow-upf ICD and biventricular pacing systems. Numbers ofrocedures as a primary operator for these technologies areiven.

The revised report “Task Force 12: Training in Advancedardiovascular Imaging” has been expanded to now includenew section on training in CT. This accompanies revised

raining guidelines in cardiovascular magnetic resonanceCMR). Both of these imaging technologies have beenharacterized by significant progress in the past 4 years sincehe last COCATS training guidelines were published. Leveltraining for gaining familiarity with cardiac CT is desig-

ated for 4 weeks, and Level 2 training is divided into 4eeks for non-contrast CT procedures and 8 weeks forrocedures using contrast. For Level 3 training, 6 monthsre recommended. This represents cumulative time spentnterpreting, performing, and learning about cardiac CT,nd need not be a consecutive block of time. The minimumumbers of mentored examinations where the trainee isresent during performance of the procedures, and whennterpretation only is required, are provided for all threeevels of clinical training for competency. A curriculum foridactic teaching in CT is also outlined.The other section of Task Force 12 includes expanded

uidelines for training in CMR. For such training, Level 1,evel 2, and Level 3 require minimal times of 1, 3, and 12onths, respectively. As with cardiac CT, the number ofentored CMR examinations for all levels of training is

rovided. For Level 2 training, 150 or more mentorednterpretations with 50 as a primary interpreter (and oper-tor, if possible) are recommended, whereas for Level 1raining, at least 50 mentored interpretations are required.s with other task force reports, a list of didactic activities

n the CMR task force report is clearly defined. As with theriginal document (1), in these revised training guidelines,ellow and trainee are used interchangeably, as are cardio-ascular medicine and cardiology. Although numbers ofrocedures that should be completed to achieve levels ofraining are provided, the mere accomplishment of suchumbers of procedures is not synonymous with excellence inheir performance and interpretation. It is vital to thexcellence of a training program that dedicated facultyembers be available to supervise and critique performance

nd interpretation of procedures.Throughout these task force reports, training is suggested

t three levels:

evel 1—Basic training required of all trainees to becompetent consultant cardiologists.

evel 2—Additional training in one or more specializedareas that enables the cardiologist to perform or interpret(or both) specific procedures at an intermediate skill levelor engage in rendering cardiovascular care in specializedareas.

evel 3—Advanced training in a specialized area thatenables a cardiologist to perform, interpret, and trainothers to perform and interpret specific procedures at ahigh skill level.

The ever-expanding knowledge base in basic cardiovas-ular science and cardiovascular medicine requires that allraining programs have a rich assortment of didactic offer-ngs for fellows. Case-based conferences, such as the tradi-ional catheterization laboratory conference, are vital to trainellows and to develop their skills in evidence-based decision-aking. Self-learning needs to be emphasized, and internet-

ased, on-line educational programs, many of which arenteractive, will play a greater role in a fellow’s overall learningxperience during fellowship and after training. Such didac-ic activities are outlined throughout the task force reports.

The ACCF/AHA/ACP Task Force makes every effort tovoid any actual or potential conflicts of interest that mightrise as a result of an outside relationship or a personalnterest of a member of its writing committees. Specifically,ll members of a writing committee are asked to provideisclosure statements of all such relationships that might beerceived as real or potential conflicts of interest relevant tohe document topic. These changes are reviewed by the

riting Committee and updated as changes occur. Theelationships with industry information for authors and peereviewers are published in the appendices of each Task Forceeport.

Please view the 2002 COCATS report at http://ww.acc.org/clinical/training/cocats2.pdf to review theCCF’s current policy for training requirements on content

reas not contained in this 2006 focused update.

EFERENCES

. COCATS Guidelines. Guidelines for Training in Adult CardiovascularMedicine, Core Cardiology Training Symposium. June 27–28, 1994.American College of Cardiology. J Am Coll Cardiol 1995;25:1–34.

. Beller GA, Bonow RO, Fuster V, et al. ACC Revised Recommenda-tions for Training in Adult Cardiovascular Medicine Core CardiologyTraining II (COCATS 2) (Revision of the 1995 COCATS TrainingStatement). 2002. American College of Cardiology Website. Available
at: http://www.acc.org/clinical/training/cocats2.pdf. Accessed January9, 2006.
http://www.acc.org/clinical/training/cocats2.pdf




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896 Beller et al. JACC Vol. 47, No. 4, 2006Introduction February 21, 2006:894–7

PPENDIX 1

Task Force Area LevelMinimal Number of

ProceduresCumulative Duration of

Training (Months)Minimal Cumulative

Number of Cases

1 Clinical cardiology 1 36

2 Electrocardiography 1 500 to 3500*† 35002 greater than 3500

Ambulatory monitoring 1 150* 1502 75 225

Exercise testing 1 200* 2002 100 300

3 Diagnostic catheterization 1 100 4 1002 200 8 300

Interventional catheterization 3 250 20 550

4 Echocardiography 1 150 3 1502 150 6 3003 450 12 750

5 Nuclear cardiology 1 80 h 2 80 h2 300 cases 4 to 6 300� cases3 600 cases 12 600� cases

6 Electrophysiology, pacing, andarrhythmias

1 20 2 10 temporary pacemakers2 100 6 10 DC cardioversions3 300 24 100 pacemaker interrogation/

reprograming150� EP cases75 ablations75� pacemaker/ICDs

7 Research 1 6 to 12‡2 243 24 to 36

8 Heart failure and transplantation 1 1‡�2 63 12

9 Congenital heart disease 1 Core lectures‡ 40 catheterizations2 12 300 TTE cases3 24 50 TEE cases

Preventive cardiology 1 1‡�2 6 to 123 12

11 Vascular medicine and peripheralcatheter-based intervention

1 2*

Vascular Medicine Specialist 2 14¶ 400� noninvasive cases#Peripheral Vascular Intervention 3 20�� 160� cases‡‡Vascular Medicine Specialist plus

Vascular Intervention3 34††

12 Advanced cardiovascularimaging—cardiovascularmagnetic resonance

123

1§3 to 6

12

50 cases150 cases300 cases

12 Advanced cardiovascularimaging—computedtomography

123

1§26

50 cases150 cases300 cases

Can be taken throughout the training program. †The committee strongly recommends that cardiologists achieve Level 2 training in electrocardiographic interpretation.Can be taken as part of 9 months of required nonlaboratory clinical practice rotation. §Can be taken as part of 6 months of noninvasive imaging rotation. �It is assumed thatrainees will obtain additional training in heart failure and preventive cardiology beyond the 1-month core training as part of the experience during other clinical months, suchs consult services and cardiac care unit. ¶2 months of vascular medicine as defined by Level 1, plus 12 months of Level 2 training. Level 2 training is not a prerequisite for Leveltraining but is intended for individuals who want to become a vascular medicine specialist. #In addition, observing 25 peripheral angiograms and 25 peripheral interventions.

*Including 2 months of vascular medicine training as defined by Level 1, 8 months of diagnostic catheterization training, and 12 months of interventional lab training.nterventional training for Level 3 requires a 4th year. The 12 months of Level 2 training are not required for this interventional training year. ††Including 2 months of Leveland 12 months of Level 2 vascular medicine training, 8 months of diagnostic catheterization training, and 12 months of interventional lab training. ‡‡Including 100 diagnosticeripheral angiograms, 50 peripheral interventions, and 10 thrombolysis/thrombectomies.

DC � direct current; EP � electrophysiologic; ICD � implantable cardioverter-defibrillator; TEE � transesophageal echocardiography; TTE � transthoracic echocardiography.

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897JACC Vol. 47, No. 4, 2006 Beller et al.February 21, 2006:894–7 Introduction

PPENDIX 2. Cochair Relationships With Industry for the ACCF 2006 Update for Training in Adultardiovascular Medicine—Introduction

Name ConsultantResearch

Grant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. George A. Beller None BMS MedicalImaging

GE Healthcare

BMS MedicalImaging

GE HealthcareVasomedical Corp.

None None None None

r. Robert O. Bonow None None None None None None None

r. Valentin Fuster GlaxoSmithKline

None VasogenKereos

None None None None

his table represents the relationships of committee members with industry that were reported by the authors as relevant to this topic. It does not necessarily reflect relationshipsith industry at the time of publication.

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ASK FORCES

ask Force 5: Training in Nuclear Cardiologyndorsed by the American Society of Nuclear Cardiologyanuel D. Cerqueira, MD, FACC, Chairaniel S. Berman, MD, FACC, Marcelo F. Di Carli, MD, FACC,einrich R. Schelbert, MD, PHD, FACC, Frans J. Th. Wackers, MD, PHD, FACC,

ublished by Elsevier Inc.

im Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative)

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he recommendations of this Joint Task Force, made up ofepresentatives of the American College of Cardiology Foun-ation (ACCF) and the American Society of Nuclear Cardi-logy (ASNC), have been approved by the governing bodies ofhe ACCF and the ASNC in January 2006.

RAINING IN NUCLEAR CARDIOLOGY

uclear cardiology (Table 1) provides important diagnosticnd prognostic information that is an essential part of thenowledge base required of the well-trained cardiologist forptimal management of the cardiovascular patient. Trainingf fellows in nuclear cardiology is divided into three levels:1

General (Level 1, 2 months): makes trainee conversantwith the field of nuclear cardiology for application ingeneral clinical management of cardiovascular patients.Specialized (Level 2, 4 to 6 months): provides trainee withspecial expertise to practice clinical nuclear cardiology.Advanced (Level 3, 1 year): provides advanced trainingsufficient to pursue an academic career or direct a nuclearcardiology laboratory.

eneral Cardiology Training Background

o have an adequate understanding of the clinical applica-ions of nuclear cardiology and to perform tests safely, theardiology trainee must acquire knowledge and proficiencyn the following areas of general cardiology:

. Coronary angiography and physiology

. Cardiac physiology and pathophysiology

. Rest and exercise electrocardiography

. Exercise physiology

. Pharmacology of standard cardiovascular drugs

. Cardiopulmonary resuscitation and treatment of othercardiac emergencies

. Pharmacology and physiology of commonly used stressagents, such as dipyridamole, adenosine, and dobutamine

. Clinical outcomes assessment

The issues of ongoing clinical competence and training or retraining of practicingardiologists are beyond the scope of this document. The Certification Board ofuclear Cardiology (CBNC) was established jointly by the ACC and ASNC and

ssesses knowledge and mastery in the areas of radiation safety and the technical andlinical performance of nuclear cardiology procedures. For additional information,

pontact CBNC at 19562 Club House Road, Montgomery Village, Maryland 20886.ttp://www.cbnc.org.

verview of Nuclear Cardiology Training

raining in nuclear cardiology at all levels should provide annderstanding of the indications for specific nuclear cardi-logy tests, the safe use of radionuclides, basics of instru-entation and image processing, methods of quality con-

rol, image interpretation, integration of risk factors, clinicalymptoms, and stress testing, and the appropriate applica-ion of the resultant diagnostic information for clinicalanagement. The depth of understanding will vary with

ach of the three levels of training. Training in nuclearardiology is best acquired in Accreditation Council forraduate Medical Education (ACGME) approved training

rograms in cardiology, nuclear medicine, or radiology. Anxception to this ACGME requirement is the didactic andaboratory training in radiation safety and radioisotopeandling that may be provided by qualified physicians/cientists in a non-ACGME program when such a programs not available as part of the clinical ACGME trainingrogram.Nuclear cardiology training consists of the components

hown in Table 2. Didactic, clinical case experience, andands-on training hours require documentation in a log-ook, having the trainee’s name appear on the clinicaleport, or having some other specific record. The hours needo be monitored and verified by the nuclear cardiologyraining preceptor. For the advanced trainee, specializedraining and research can be derived as part of an establishedrogram in either cardiology or a division of nuclearedicine. The person(s) responsible for the didactic, clini-

al, and hands-on training and experience are responsibleor evaluating the competence of the trainee in nuclearardiology upon completion of the program. This can beccomplished by observing the daily performance of theellow, a formal testing procedure, or both. The preceptoror specialized or advanced training should have Level 3 (orhe equivalent) training in nuclear cardiology.

idactic Program

ectures and self-study. This component is composed ofectures on the basic aspects of nuclear cardiology andarallel self-study material consisting of reading and viewingases on video or CD. The lectures and reading should
rovide the fellow with an understanding of the clinical
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899JACC Vol. 47, No. 4, 2006 Cerqueira et al.February 21, 2006:898–904 Task Force 5: Training in Nuclear Cardiology

pplications of nuclear cardiology, including imaging withositron-emitting radionuclides and computed tomographyCT) hybrid systems including single-photon emissionomputed tomography (SPECT)/CT and positron emis-ion tomography (PET)/CT. The material covered shouldnclude radiopharmaceuticals, radiation physics instrumen-ation, nuclear cardiology diagnostic tests, and procedures/rotocols, general cardiology as it relates to image interpre-ation, risk stratification, myocardial perfusion imaging,entricular function imaging, and assessment of myocardialiability. Specificity, sensitivity, diagnostic accuracy, utilityn assessing prognoses and interventions, costs, indications,nd pitfalls in interpretation and clinical application must bemphasized for each patient subset.

This program may be scheduled over a 12- to 24-montheriod, concurrent with other fellowship assignments. Somef the information can be effectively transmitted as part of aeekly non-invasive or invasive cardiology conference withresentation and discussion of nuclear cardiology imageata.adiation safety. The second component of the didacticrogram should provide the fellow with an understanding ofadiation safety as it relates to patient selection and admin-stration of radiopharmaceuticals and utilization of CTystems. Fellows seeking Level 2 or Level 3 training willequire greater in-depth knowledge as well as hands-onractical experience. These are detailed for each level.

nterpretation of Clinical Cases

uring training, fellows should actively participate in dailyuclear cardiology study interpretation under the direction

able 1. Classification of Nuclear Cardiology Procedures

. Standard nuclear cardiology proceduresa. Myocardial perfusion imaging

i. SPECT with technetium-99m agents and thallium-201ii. PET with rubidium-82 and nitrogen-13 ammoniaiii. Planar with technetium-99m agents and thallium-201iv. ECG gating of perfusion images for assessment of global and

regional ventricular functionv. Imaging protocolsvi. Stress protocols

1. Exercise stress2. Pharmacologic stress

vii. Viability assessment including reinjection and delayedimaging of thallium-201 and metabolic imaging whereavailable

b. Equilibrium gated blood pool or “first pass” radionuclideangiography at rest and during exercise or pharmacologic stress

c. Qualitative and quantitative methods of image display andanalysis

. Less commonly used nuclear cardiology proceduresa. Combined myocardial perfusion imaging with cardiac CTb. Metabolic imaging using single-photon and/or positron-emitting

radionuclidesc. Myocardial infarct imagingd. Cardiac shunt studies

T � computed tomography; ECG � electrocardiographic; PET � positronmission tomography; SPECT � single-photon emission computed tomography.

f a qualified preceptor in nuclear cardiology. For all studies

n which angiographic or hemodynamic data are available,uch information should be correlated with the nuclearardiology studies. Although experience in all aspects ofuclear cardiology is recommended, some procedures mayot be available—or may be performed in low volume—inome training programs. Under such circumstances, andequate background for general fellowship training can beatisfied with appropriate reading or review of case files.raining in nuclear cardiology needs to include extensive

xperience with the standard nuclear cardiology proceduresnd as much exposure as possible to the less commonlyerformed procedures. The training program needs torovide a teaching file consisting of perfusion and ventric-lar function studies with angiographic documentation ofisease.

ands-On Experience

linical cases. Fellows should have hands-on supervisedxperience in an appropriate number of the standard proce-ures (e.g., myocardial perfusion imaging and radionuclidengiography) and as many of the less commonly performedrocedures as possible. Such experience should include pretestatient evaluation; radiopharmaceutical preparation—easuring the dose, administration, and experience with rele-

ant radionuclide generators; operation and quality control oflanar and SPECT gamma camera and CT systems; setup ofhe imaging computer; utilization of electrocardiogram (ECG)ating; performing treadmill, bicycle, and pharmacologic stressesting techniques; processing the data for display; interpretinghe study; and generating a clinical report. Complete nuclearardiology studies should be performed under the supervisionf qualified personnel.adiation safety. Fellows need to be familiar with radia-

ion biology and the regulations governing the use ofadioactive materials and ionizing radiation for performingiagnostic nuclear cardiology and hybrid CT studies. Thisnowledge includes details for protecting patients, theublic, and the user from the effects of radiation.

ENERAL TRAINING—EVEL 1 (MINIMUM OF 2 MONTHS)

he trainee is exposed to the fundamentals of nuclearardiology for a minimum period of 2 months duringraining. This 2-month experience provides familiarity withuclear cardiology technology and its clinical applications inhe general clinical practice of adult cardiology, but it is notufficient for the specific practice of nuclear cardiology. The

able 2. Nuclear Cardiology Training Components

. Didactic programa. Lectures and self-studyb. Radiation safety

. Interpretation of clinical cases

. Hands-on experiencea. Clinical cases
b. Radiation safety

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900 Cerqueira et al. JACC Vol. 47, No. 4, 2006Task Force 5: Training in Nuclear Cardiology February 21, 2006:898–904

hree components of training include a didactic programhat includes lectures, self-study, radiation safety and regu-ations, interpretation of nuclear cardiology studies, andands-on experience.

idactic Program

ectures and self-study. This component consists of lec-ures on the basic aspects of nuclear cardiology and parallelelf-study material consisting of reading and viewing caseles. The material presented should integrate the role ofuclear cardiology into total patient management. Such

nformation can be included within a weekly non-invasive ornvasive cardiology conference, with presentation and dis-ussion of nuclear cardiology image data as part of diagnos-ic and therapeutic management.

nowledge and appreciation of radiation safety. Theidactic program should include reading and practical ex-erience with the effects of radiation and provide the fellowith an understanding of radiation safety as it relates toatient selection and administration of radiopharmaceuti-als and utilization of CT systems.

nterpretation of Nuclear Cardiology Studies

uring the 2-month rotation, fellows should actively par-icipate in daily nuclear cardiology study interpretationminimum of 80 h). Experience in all the areas listed inable 1 is recommended. If some procedures are not

vailable or are performed in low volume, an adequateackground for general fellowship training can be satisfiedy appropriate reading or review of case files. The teachingle should consist of perfusion and ventricular functiontudies with angiographic/cardiac catheterization documen-ation of disease.

ands-On Experience

ellows should perform complete nuclear cardiology studieslongside a qualified technologist or other qualified laboratoryersonnel. They should, under supervision, observe and par-icipate in a large number of the standard procedures and asany of the less commonly performed procedures as possible.ellows should have experience in the practical aspects of

adiation safety associated with performing clinical patienttudies.

PECIALIZED TRAINING—EVEL 2 (MINIMUM OF 4 MONTHS)

ellows who wish to practice the specialty of nuclear cardiologyre required to have at least 4 months of training. This includesminimum of 700 h of didactic, clinical study interpretation

nd hands-on clinical case and radiation safety training inuclear cardiology. In training programs with a high volume ofrocedures, clinical experience may be acquired in as short aeriod as 4 months. In programs with a lower volume ofrocedures, a total of six months of clinical experience will be
ecessary to achieve Level 2 competency. The additional
sa

raining required of Level 2 trainees is to enhance their clinicalkills and qualify them to become authorized users of radioac-ive materials in accordance with the regulations of the Nuclearegulatory Commission (NRC) and/or the agreement states.2

idactic Program

ectures and self-study. The didactic training shouldnclude in-depth details of all aspects of the proceduresisted in Table 1. This program may be scheduled over a 12-o 24-month period concurrent and integrated with otherellowship assignments.

adiation safety. Classroom and laboratory training needo include extensive review of radiation physics and instru-entation, radiation protection, mathematics pertaining to

he use and measurement of radioactivity, chemistry ofyproduct material for medical use, radiation biology, theffects of ionizing radiation and radiopharmaceuticals.here should be a thorough review of regulations dealingith radiation safety for the use of radiopharmaceuticals and

onizing radiation. This experience should total a minimumf 80 h and be clearly documented.

nterpretation of Clinical Cases

ellows should participate in the interpretation of all nuclearardiology imaging data for the 4- to 6-month trainingeriod. It is imperative that the fellows have experience inorrelating catheterization or CT angiographic data withadionuclide-derived data for a minimum of 30 patients. Aeaching conference in which the fellow presents the clinicalaterial and nuclear cardiology results is an appropriate

orum for such an experience. A total of 300 cases should benterpreted under preceptor supervision from direct patienttudies (Table 3).

ands-On Experience

linical cases. Fellows acquiring Level 2 training shouldave hands-on supervised experience with a minimum of 35atients: 25 patients with myocardial perfusion imaging and0 patients with radionuclide angiography. Such experience

Level 2 and Level 3 training meet eligibility criteria for taking the Certificationoard of Nuclear Cardiology examination and NRC training and experience

equirements to become an authorized user. The NRC establishes federal policy withegard to the medical use of nuclear reactor byproduct materials. Currently, there are3 states that have applied and been approved by the NRC to self-regulate the use ofadioactive materials, so-called “agreement states.” The other 19 states are regulatedy the federal policy. There is variation within the agreement states in the training andxperience requirements for physicians applying to become authorized users ofadioactive materials for diagnostic testing. The NRC requires only that thegreement state requirements be as stringent as the federal NRC policy, but statesave the authority to make the requirements more stringent. Some states require areater number of total hours for the didactic, classroom, and laboratory experience inadiation safety. Other states have restricted the acceptable programs or institutionshere such training hours may be acquired. Given this variability in training and

xperience requirements within the U.S., trainees are advised to contact the NRC andhe agreement states where they may seek to become authorized users of radioactiveaterials for the current rules and requirements. For details contact the agreement

tates’ homepage at http://www.hsrd.ornl.gov/nrc/home.html. Click on directory andhen click on directory of agreement states and non-agreement state directors and
tate liaison officers. This will provide information on contacting the individual statesnd getting the specific licensure requirements.
http://www.hsrd.ornl.gov/nrc/home.html

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hould include pre-test patient evaluation, radiopharmaceu-ical preparation (including experience with relevant radio-uclide generators and CT systems), performance of thetudy, administration of the dosage, calibration, and setup ofhe gamma camera and CT system, setup of the imagingomputer, processing the data for display, interpretation ofhe studies, and generating clinical reports.

adiation safety work experience. This experience shoulde acquired continuously during training in the clinicalnvironment where radioactive materials are being used andnder the supervision of an authorized user who meets theRC requirements of Part 35.290 or Part 35.290(c)(ii)(G)

nd Part 35.390 or the equivalent agreement state require-ents, and must include:

. Ordering, receiving, and unpacking radioactive materi-als safely and performing the related radiation surveys;

. Performing quality control procedures on instrumentsused to determine the activity of dosages and perform-ing checks for proper operation of survey meters;

. Calculating, measuring, and safely preparing patient orhuman research subject dosages;

. Using administrative controls to prevent a medical eventinvolving the use of unsealed byproduct material;

. Using procedures to safely contain spilled radioactivematerial and using proper decontamination procedures;

. Administering dosages of radioactive material to patientsor human research subjects; and

. Eluting generator systems appropriate for preparation ofradioactive drugs for imaging and localization studies,measuring and testing the eluate for radionuclide purity,and processing the eluate with reagent kits to preparelabeled radioactive drugs.

dditional Experience

he training program for Level 2 must also provide expe-ience in computer methods for analysis. This should includeerfusion and functional data derived from thallium or tech-etium agents and ejection fraction and regional wall motioneasurements from radionuclide angiographic studies.

ADVANCED TRAINING—EVEL 3 MINIMUM OF 1 YEAR)

or fellows planning an academic career in nuclear cardiol-gy or a career directing a clinical nuclear cardiologyaboratory, an extended program is required. This may beart of the standard three-year cardiology fellowship. Inddition to the recommended program for Level 2, theevel 3 program should include advanced quality control ofuclear cardiology studies and active participation andesponsibility in ongoing laboratory or clinical research. Inarallel with participation in a research program, the traineehould participate in clinical imaging activities for the totalraining period of 12 months, to include supervised inter-retative experience in a minimum of 600 cases. Hands-on
xperience should be similar to, or greater than, that
*i

equired for Level 2 training. The fellow should be trainedn most of the following areas:

Qualitative interpretation of standard nuclear cardiologytudies, including myocardial perfusion imaging, ECG-ated perfusion studies, gated equilibrium studies, “first-ass,” and any of the less commonly performed proceduresvailable at the institution

Quantitative analysis of perfusion and/or metabolic studiesQuantitative radionuclide angiographic and gated perfu-sion analyses, including measurement of global andregional ventricular functionSPECT perfusion acquisition, reconstruction, and displayECG-gated SPECT perfusion acquisition, analysis, anddisplay of functional dataImaging of positron-emitting tracers using either dedi-cated PET systems or SPECT-like systems equippedwith either high-energy photon collimators or coinci-dence detection

he requirements for Level 1 to 3 training in nuclearardiology are summarized in Table 3.

pecific Training in Cardiacmaging of Positron-Emitting Radionuclides

ardiac PET and PET/CT imaging of positron-emittingadionuclides are part of nuclear cardiology. For institutionshat have positron imaging devices, training guidelines areppropriate. Training in this particular imaging technologyhould go hand-in-hand and may be concurrent withraining in conventional nuclear cardiology. Such traininghould include those aspects that are unique or specific tohe imaging of positron-emitting radionuclides. Dependingn the desired level of expertise, training in cardiac PET andmaging with positron-emitting radionuclides should in-lude knowledge of substrate metabolism in the normal andiseased heart; knowledge of positron-emitting tracers forlood flow, metabolism and neuronal activity, medical cyclo-rons, radioisotope production, and radiotracer synthesis; andrinciples of tracer kinetics and their in vivo application for theon-invasive measurements of regional metabolic and func-ional processes. The training should also include the physicsf positron decay, aspects of imaging instrumentation spe-ific to imaging of positron emitters and the use of CT,roduction of radiopharmaceutical agents, quality control,andling of ultrashort life radioisotopes, appropriate radia-ion protection, and safety and regulatory aspects.

able 3. Summary of Training Requirements foruclear Cardiology

evelMinimum Duration

of Training Total No. of Examinations

1 2 months 80 h interpretative experience2 4–6 months 300*3 12 months 600*

A minimum of 35 cases with hands-on experience must be performed andnterpreted under supervision.

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902 Cerqueira et al. JACC Vol. 47, No. 4, 2006Task Force 5: Training in Nuclear Cardiology February 21, 2006:898–904

Consistent with the training guidelines for general nuclearardiology, training should be divided into three classes.

ENERAL TRAINING (2 MONTHS)

his level is for cardiology fellows who are associated with annstitution where PET and/or PET/CT devices are available andho wish to become conversant with cardiac positron imaging.raining should therefore be the same as for Level 1 training inuclear cardiology but should include aspects specific to cardiacositron imaging. The additional proficiency to be acquired byhysician trainees includes background in substrate metabolism,atient standardization, and problems related to diabetes mellitusnd lipid disorders, positron-emitting tracers of flow, and metab-lism and technical aspects of positron and CT imaging. Aidactic program should include the interpretation of cardiac PETtudies of myocardial blood flow and substrate metabolism, thenterpretation of studies combining SPECT for evaluation oflood flow with PET for evaluation of metabolism, the evaluationf diagnostic accuracy and cost-effectiveness of viability assessmentf coronary artery disease detection, and the understanding ofadiation safety as specifically related to positron emitters.ands-on experience should include supervised observation and

nterpretation of cardiac studies performed with positron-emittingadionuclides and PET and PET/CT imaging devices.

PECIALIZED TRAINING (MINIMUM OF 4 MONTHS)

his level of training is for fellows who wish to perform andnterpret cardiac PET or positron-imaging studies in addi-ion to nuclear cardiology. This training should include allevel 1 and Level 2 training in nuclear cardiology (4 to 6onths) as well as general training for cardiac PET andET/CT. Specific aspects of training for PET and for usingositron-emitting radionuclides should include radiationosimetry, radiation protection and safety, dose calibration,hysical decay rates of radioisotopes, handling of large dosesf high energy radioactive materials of short physical half-ives, quality assurance procedures, and NRC safety andecord-keeping requirements. This level of training requiresirect patient experience with a minimum of 40 patienttudies of myocardial perfusion or metabolism, or both.

DVANCED TRAINING (MINIMUM 1 YEAR)

his level of training is intended for fellows planning ancademic career in cardiac PET or who wish to direct alinical cardiac PET laboratory. Similar to Level 3 trainingn nuclear cardiology, this training should include activearticipation in laboratory and clinical research in parallelith clinical activities.In addition to the requirements for general and special-

zed cardiac PET training (including standard nuclear cardi-logy training, as previously described), advanced training
hould include the following:
. Basic principles of cyclotrons, isotope production, ra-diosynthesis, tracer kinetic principles and tracer kineticmodels, cardiac innervation and receptors, and methodsfor quantifying regional myocardial blood flow andsubstrate metabolism.

. Imaging instrumentation including dedicated PET sys-tems, hybrid PET/CT systems, and SPECT-like positronimaging devices with high-energy photon collimators orcoincidence detection. Image acquisition and processingto include review of sinograms, errors in image recon-struction, correction routines for photon attenuation,and patient misalignment.

. Tissue kinetics of positron-emitting tracers; in vivoapplication of tracer kinetic principles; tracer kineticmodels, generation of tissue time activity curves, andcomputer-assisted calculation of region of functionalprocesses of the myocardium.

. Computer-assisted data manipulation, quantitative im-age analysis, and image display.

ybrid CT Imaging

ybrid imaging devices combining PET or SPECT withT are playing an increasing role in the field of cardiac

maging. Currently, nearly all PET scanners are sold asET/CT devices, and SPECT/CT machines are nowvailable from most manufacturers. As these devices becomeore widely disseminated, it will be important that training

uidelines for their use be developed both for fellows inraining and cardiologists already in practice. The applica-ions of hybrid imaging in cardiology include the use of CTcanning to provide robust attenuation correction ofPECT or PET and to assess coronary calcium as a markerf coronary atherosclerosis. Even these non-contrast appli-ations of hybrid imaging will require additional trainingeyond that required for CT alone. With CT coronaryalcium and SPECT or PET perfusion assessments, addi-ional training will be needed regarding discordant results.

ith contrast injection, high-resolution CT coronary an-iography can be combined with rest/stress assessments ofyocardial perfusion provided by PET and SPECT, allow-

ng functional assessment of the anatomic findings. Thepecifics of the training required in hybrid imaging areeyond the scope of this document; nonetheless, thoseuclear cardiology training programs that are equipped toerform hybrid imaging should incorporate training in thiseld in their programs. Training should include the physicsf hybrid systems, CT attenuation correction, principlesnd application of CT coronary calcium assessment,nd principles and application of CT coronary angiography.his is an update of the 2002 document that was written byanuel D. Cerqueira, MD, FACC, Heinrich R. Schelbert,D, PhD, FACC, Frans J. Th. Wackers, MD, PhD, FACC,

nd Mario Verani, MD, FACC.

10.1016/j.jacc.2005.12.027

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PPENDIX 1. Author Relationships With Industry for the ACCF 2006 Update for Training in Adultardiovascular Medicine—Task Force 5: Training in Nuclear Cardiology


Grant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. Daniel S. Berman Tyco-Mallincrodt BMSAstellasGE Healthcare

SpectrumDynamics

None None SpectrumDynamics

Cedars-SinaiMedicalCenter–SoftwareRoyalites

r. Manuel D. Cerqueira GE HealthcareCVTAstellas

None CVT GE HealthcareCVTAstellas

None None BMS-DSMB

r. Marcelo F. DiCarli None None None None None None None

r. Heinrich R. Schelbert None None None None None None None

r. Frans J. Th. Wackers None BMSGE HealthcareAstellasAcusphereBracco

King Pharm GE Healthcare None None MedX(WLCQsoftware)–Royalties

r. Kim Allan Williams King GE HealthcareBMSCVT

GE Healthcare GE HealthcareAstellas

None None None


PPENDIX 2. External Peer Reviewer Relationships With Industry for the ACCF 2006 Update for Trainingn Adult Cardiovascular Medicine—Task Force 5: Training in Nuclear Cardiology*

Peer ReviewerName† Representation Consultant

ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. JamesArrighi

ACC OfficialReviewer–Board ofGovernors

None None None None None None None

r. KennethA. Brown

Content Reviewer–Individual Review

None BMSKing

Pharmaceuticals

None None None None None

r. MaleahGrover-McKay

Content Reviewer–ACCFCardiovascularImagingCommittee

Tarctegen None None None None None None

r. Gary V.Heller

OrganizationalReviewer–AmericanSociety of NuclearCardiology

None BraccoDiagnosticGE MedicalBMSMedicalImagingPhilips Medical


r. Ami E.Iskandrian

Content Reviewer–ACCFCardiovascularImagingCommittee

CVTherapeuticsInternational

AtomicEnergy

Agency

Astellas PharmMolecularInsight

Corp.GE MedicalCVTherapeuticsBMS

None None None None AcusphereInc.–BlindedReader

Continued on next page

his table represents the relevant relationships of peer reviewers with industry to this topic that were disclosed at the time of peer review of this guideline. It does not necessarily
eflect relationships with industry at the time of publication. *Participation in the peer review process does not imply endorsement of the document. †Names are listed inlphabetical order.

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904 Naccarelli et al. JACC Vol. 47, No. 4, 2006Task Force 6: Training in Specialized EP, Cardiac Pacing, and Arrhythmia Management February 21, 2006:904–10

PPENDIX 2. Continued


ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. VincentRobinson

OrganizationalReviewer–AmericanSociety of NuclearCardiology


r. JamesUdelson

ACC Official Reviewer–Board of Trustees

MolecularInsight

PharmKing Pharm

GE Healthcare MolecularInsight

PharmKing

Pharm

None MolecularInsight

PharmKing

Pharm

None None

ask Force 6: Training inpecialized Electrophysiology,ardiac Pacing, and Arrhythmia Management

ndorsed by the Heart Rhythm Societyerald V. Naccarelli, MD, FACC, Chair

amie B. Conti, MD, FACC, John P. DiMarco, MD, PHD, FACC,
ynthia M. Tracy, MD, FACC (Heart Rhythm Society Representative)
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linical cardiac electrophysiology and cardiac pacingave merged into a common cardiac subspecialty disci-line. Today, complex cardiac arrhythmias are managedy physicians with special expertise in cardiac electro-hysiology, the use of implantable pacemakers and im-lantable cardioverter-defibrillators (ICDs), and the ap-lication of other interventional techniques andreatments. Non-pharmacologic therapy also includeslectrophysiologic mapping and subsequent catheter orurgical ablation as standard treatment for certain tachy-rrhythmias. In addition, antiarrhythmic agents withiverse mechanisms of action are often used therapeuti-ally alone or in conjunction with cardiac implantablelectrical devices.

In 1986, a Task Force 6 report on training in cardiacacing (1) was published as a result of Bethesda Confer-nce 17 on adult cardiology training. In 1991, a trainingtatement recommending guidelines for training in adultlinical cardiac electrophysiology was published (2). In995, a task force (3) combined these two closely relatedisciplines to reflect the current merging of science, art,nd the practice of clinical cardiac electrophysiology. In002, updated recommendations were published (4). Theurrent task force is charged with updating these traininguidelines based on changes in the pacing and cardiac
lectrophysiology field since that time. A
ENERAL STANDARDS AND ENVIRONMENT

acilities and Faculty

hree organizations—the American College of CardiologyACC), the American Heart Association (AHA), and the Hearthythm Society (HRS)—have addressed training requirements

nd guidelines for permanent pacemaker selection, implantation,nd follow-up (5,6); guidelines for the implantation and follow-upf ICDs in cardiovascular practice (7,8); guidelines for training inatheter ablation procedures (9,10); and teaching objectives forellowship programs in clinical electrophysiology (11,12). Theraining recommendations for these three organizations areongruent and address new technologies, faculty, and facilityequirements, as well as practice. It is strongly recommendedhat trainees who desire admission to the American Boardf Internal Medicine (ABIM) examination for certificationn cardiovascular diseases and those who seek admission tohe Clinical Cardiac Electrophysiology (CCEP) examina-ion for certification of added qualifications in clinicalardiac electrophysiology be certain to obtain specific re-uirements from the ABIM (13,14).The cardiac arrhythmia aspects of a cardiology training

rogram should meet the published recommendations andequirements regarding facilities and faculty (9,10). In orderor trainees to be eligible for admission to the CCEPxamination of the ABIM, training must take place in an
ccreditation Council for Graduate Medical Education

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905JACC Vol. 47, No. 4, 2006 Naccarelli et al.February 21, 2006:904–10 Task Force 6: Training in Specialized EP, Cardiac Pacing, and Arrhythmia Management

ACGME)-approved training program (13). The intensityf training and the required teaching resources may varyccording to the level of training provided. Facilities shoulde adequate to ensure a safe, sterile, and effective environ-ent for invasive electrophysiologic studies and implanta-

ion of arrhythmia control devices. Faculty should includepecialists who are skilled in the medical and surgical aspectsf pacing and electrophysiology. In addition, faculty shoulde knowledgeable about the risks to the patient and toedical personnel from radiation exposure. Faculty respon-

ible for training must be board certified in clinical cardiaclectrophysiology or possess equivalent qualifications. Inddition, there must be a minimum of two key clinicalardiac electrophysiology faculty members, including therogram director. In programs with a total of more than twoesidents enrolled, a ratio of such faculty to residents of ateast 1:1 must be maintained (13).

EVELS OF TRAINING

evel 1

ithin the cardiology core training program, Level 1 shouldomprise at least 2 months of clinical cardiac electrophysiologyotation designed for cardiology trainees to acquire knowledgend experience in the diagnosis and management of brady-rrhythmias and tachyarrhythmias. Every cardiology traineehould learn the indications for and limitations of electrophysi-logic studies, the appropriate use of pharmacologic andon-pharmacologic therapeutic options, and the proper andppropriate use of antiarrhythmic agents, including drug inter-ctions and proarrhythmic potential. The Level 1 traineehould be exposed to non-invasive and invasive techniqueselated to the diagnosis and management of patients withardiac arrhythmias that include ambulatory electrocardio-raphic (ECG) monitoring, event recorders, exercise testingor arrhythmia assessment tilt-table testing invasive electro-hysiologic studies, and implantation of cardiac arrhythmiaontrol devices. Electrocardiographic manifestations of ar-hythmias should be taught on a regular basis during formalCG conferences. Additional experience in heart rhythmisorders and clinical correlations can be obtained fromidactic sessions and conferences; however, they must beupplemented by rotation on an arrhythmia consultationervice, during which time the trainee should gain first-handxperience as a consultant in arrhythmia management.rrhythmias associated with congenital heart disease, car-iac and non-cardiac surgical patients, are important com-onents of the arrhythmia core training.The Level 1 cardiology trainee’s experience should also

nclude learning the fundamentals of cardiac pacing, recog-izing normal and abnormal pacemaker function, knowing

ndications for temporary and permanent pacing and themplantation of ICDs (5), knowing pacing modes, andnderstanding basic techniques for interrogation, program-
ing, and surveillance of pacemakers and ICDs. Trainees a
hould learn about the indications for the use of biventricu-ar pacing in patients with congestive heart failure.

The cardiology trainee should be formally instructed in andain experience with the insertion, management, andollow-up of temporary pacemakers (4); measurement of pac-ng and sensing thresholds and recording of electrograms for

anagement of patients with temporary pacemakers; andndications and techniques for elective and emergency cardio-ersions (15). Insertion of a minimum of 10 temporaryacemakers and performance of at least 10 elective cardiover-ions are required. The cardiology trainee should be formallynstructed in and gain experience with the application of andse of transcutaneous pacing systems. These experiences can bebtained throughout the 24-month clinical training period.

evel 2

ome trainees in cardiology may wish to acquire advancedraining in management of arrhythmias but not undertakeraining in all aspects of cardiac electrophysiology. Such Level

training would be appropriate for individuals who wish toave careers with a substantial proportion of their time spent asheart station or ECG laboratory director or in a pacemaker or

CD follow-up or syncope evaluation service or actively in-olved in the interrogation and programming of cardiac im-lantable electrical devices on a heart failure service.Level 2 trainees should meet all Level 1 training require-ents and should obtain advanced training in normal and

bnormal cardiac electrophysiology and mechanisms of ar-hythmias. Level 2 training consists of a minimum of 6 monthsf training in non-invasive arrhythmia management techniquesesigned to develop advanced competence and proficiency inhe diagnosis, treatment, and longitudinal care of patients withomplex arrhythmias. Exposure and proficiency in the perfor-ance and interpretation of other non-invasive tests related to

he evaluation of patients who have arrhythmias should be partf the training. Level 2 trainees should have a thoroughnowledge of the basic and clinical pharmacology of antiar-hythmic agents and demonstrate proficiency in their use.

Of special importance for the Level 2 trainee is thecquisition of skills and experience for managing inpatientsnd outpatients with complex cardiac arrhythmias, includ-ng programming and follow-up management of all types ofradycardia pacing, biventricular pacing, and ICD systems.he trainee is expected to function as the primary program-ing operator who interrogates, interprets, prescribes, and

eprograms devices in at least 100 patients. The trainee at thisevel must also acquire advanced expertise in temporary pacing,ardioversion, interpretation of invasive electrophysiologictudy data, and complex arrhythmia ECG interpretation.

Although the Level 2 trainee must have significantxposure to invasive electrophysiology, ICDs, and the sur-ical aspects of arrhythmia control device implantation,evel 2 training by itself does not qualify the trainee toerform these invasive procedures. The Level 2 trainee hashe option of obtaining additional training in the surgical
spects of pacemaker implantation or may choose the

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dditional training required for invasive cardiac electrophys-ology, or both, as described under Level 3.

evel 3

his level of training is designed for the individual whoishes to specialize in invasive diagnostic and therapeutic

ardiac electrophysiology (clinical cardiac electrophysiology)16). Requirements of Level 1 and Level 2 must be fully met.

Clinical cardiac electrophysiology training will include ainimum of 4 years of training in clinical cardiology and

lectrophysiology. Current ACGME requirements specify a-year training program in general cardiology, which con-ists of a core 24-month clinical program and an additional2 months, which may involve research and elective time inlectrophysiology. A dedicated fourth year of training inlinical cardiac electrophysiology after 3 years is required.iven the complexity of the field and the growing amount

f information and new procedures, it is common forrainees to extend training for an additional year or more toain advanced expertise in specific procedures. The appro-riate use, safe performance, and judicious interpretation ofhese complex procedures requires highly specialized train-ng and competence and cannot be accomplished in a 3-yearraining program. Furthermore, an advanced knowledgease in basic clinical cardiac electrophysiology and pharma-ology must provide a sound foundation for the acquisition ofechnical abilities and cognitive skills in the management ofatients with complex arrhythmias.To complete Level 3, in addition to Level 1 and Level 2

equirements, trainees should perform at least 150 electro-hysiologic procedures and “be a primary operator andnalyze 100 to 150 initial diagnostic studies. At least 50 to5 of these procedures should involve patients with su-raventricular arrhythmias. Because therapy with antiar-hythmic devices forms a major part of current electrophys-ology practice, the trainee should also have been a primaryperator during �25 electrophysiological evaluations ofmplantable antiarrhythmic devices” (17).

Electrophysiologic procedures should cover the totalpectrum of arrhythmias, both supraventricular and ventric-lar tachyarrhythmias as well as bradyarrhythmias. Traineesho wish to become skilled in some of the more complex

lectrophysiology procedures (e.g., ablation for atrial fibril-

able 1. Cardiac Arrhythmia and Electrophysiology Curriculum

evel Curriculum/Skills Time Requi

1 Cardiac arrhythmia andelectrophysiology core

2 months (in additiontraining requiremen

2 Advanced noninvasive arrhythmiamanagement

6 months

3 Clinical invasive cardiacelectrophysiology (meets theABIM CCEP examinationrequirements)

1 yr

BIM � American Board of Internal Medicine; CCEP � Clinical Cardiac Electro

ation or evaluation of patients with congenital heart dis- t

ase) would benefit from a longer period of training orost-training mentored practice.Expertise in catheter placement, programmed electrical

timulation, endocardial mapping, catheter ablation, andnterpretation of data must be ensured by the electrophys-ology program director. The endocardial mapping experi-nce should include cases of left heart mapping by theetrograde aortic approach. Training in transseptal cathe-erization should be provided by an individual at theraining institution with expertise in the technique. Expe-ience with at least 10 transseptal catheterization proceduress suggested as minimal required training. Participation in a

inimum of 75 catheter ablations, including ablation andodification of the atrioventricular (AV) node, AV acces-

ory pathways, atrial flutter, and atrial and ventricularachycardia, is required (17). To gain expertise in atrialbrillation ablation requires additional expertise in catheteranipulation and integration of knowledge related to three-

imensional mapping systems. Given the rapid evolution ofew mapping technologies, it is unlikely that the trainee wille exposed to all mapping technologies as part of theirraining. Trainees should be exposed to tools for definitionf intracardiac anatomy, such as intravascular ultrasound,ardiac magnetic resonance imaging, and computed tomo-raphic scans. No numeric guidelines have been establishedor training in atrial fibrillation ablation, but it is anticipatedhat the Level 3 trainee should participate in 30 to 50entored atrial fibrillation ablations.The trainee in electrophysiology requires ICD experience

hat includes assisting with the primary device implantation,ith electrophysiologic testing at the time of implantation, andith follow-up assessment. This experience will include at least0 device evaluations (combined implantation and follow-up).he trainee in electrophysiology also requires experience in left

entricular lead implantation procedures. Implantable cardio-erter defibrillator implant exposure includes assisting with theevice implantation, threshold and defibrillation thresholdDFT) testing at the time of implant and follow-up. Thisxperience should include at least 15 device evaluations (im-lantation and follow-up). Although the Level 3 trainee mustave significant exposure to the management and follow-up ofCD pacemaker implantation, he or she will not necessarily be

ing Summary

nt Optional Training in Device Implantation

ask Force 2 No

Yes: In addition to 6 months of noninvasive emphasis,another 6 months for a total of 12 months isrequired for pacemaker implantation training

Yes: A total of 1 yr beyond the 3-yr cardiologytraining program is required. If surgical aspects ofdevice implantation are desired, a total of 12months will need to be devoted to this discipline.

logy.

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nless they meet Level 3 training listed below in optionalraining for device implantation.

PTIONAL TRAINING IN DEVICE IMPLANTATIONAPPLICABLE TO LEVEL 2 OR LEVEL 3)

evel 2 and Level 3 trainees may choose to obtain additionalraining in the surgical aspects of device implantation. Thisevice implantation training may be obtained concurrentlyr sequentially with Level 2 or Level 3 training, respectively.or those cardiology trainees who elect to obtain proficiency

n the surgical aspects of transvenous bradycardia devicemplantation (pacemakers), previous or concurrent Level 2raining is required. The pacemaker implantation trainingust include development of expertise in permanent atrial

ight and left ventricular lead and ICD lead placement,hreshold testing and programming of devices, principles ofurgical asepsis, surgical techniques of implantation, andanagement of implant-related complications. Individuals

eceiving qualifying training in pacemaker implantationust participate as the primary operator (under direct

upervision) in at least 50 primary implantations of trans-enous pacemakers and 20 pacemaker system revisions oreplacements. At least one-half of the implantations shouldnvolve dual-chamber pacemakers. The trainee must alsoarticipate in the follow-up of at least 100 pacemakeratient visits and acquire proficiency in advanced pacemakerlectrocardiography, interrogation, and programming ofomplex pacemakers. Level 2 training (6 months) with theption of training in pacemaker implantation (6 months)equires a total of 1 year of advanced training beyond theardiology core Level 1. This may be obtained within a-year cardiology program if 1 of the 3 years is dedicated tocquiring pacemaker implantation skills plus related man-gement and follow-up skills. This training does not meethe ABIM requirements for admission to the CCEP exami-ation. As part of the training regarding implantable pacemak-rs, exposure to the indications, implantation techniques,nd follow-up of loop recorders is desirable.

The trainee pursuing a career in cardiac electrophysiologys addressed under Level 3 also has the option of obtainingxpertise in the surgical aspects of pacemaker or transvenousCD implantation, or both. The same amount of surgicalxperience with bradycardia pacemaker implantation is re-uired and may be supplemented with surgical training forCD implantation (16). If the Level 3 trainee chooses thisption, he or she must participate as the primary implanterunder direct supervision) in at least 25 ICD system im-lantations, as well as possess the management andollow-up skills addressed under Level 3. The Level 3 traineeishing to become proficient in implantation of biventricularacing or defibrillating systems requires the above training andnvolvement in implantation and follow-up of 15 biventricularystems (6). He or she should be proficient at interpretingata gained from non-invasive tools such as echocardiogra-
hy used in the evaluation of resynchronization therapies. f
acemaker lead extraction is a specialized procedure thatequires special training but is not an obligate part ofraining for CCEP examination eligibility. Physicians beingrained in lead extraction should perform a minimum of 20ead extractions as the primary operator under the directupervision of a qualified training physician (18).

Level 3 trainees for ICD implantation must have anxtensive knowledge of ICD indications, contradictions,nd management of complications; an ability to determineefibrillation thresholds and manage high defibrillationhresholds; an understanding of drug-ICD and pacemaker-CD interactions; and a thorough knowledge of ICDrogramming and management of ICD malfunction andost-operative complications. The trainee must also partic-pate in the surgical replacement or revision of at least 10CD systems and follow-up of at least 50 ICD patient visits.evel 3 training with the option of pacemaker or ICD

mplantation or both requires a minimum of one year ofedicated clinical cardiac electrophysiology and device im-lantation training beyond the three-year cardiology pro-ram. In addition, Level 3 trainees must have an extensivenowledge of left ventricular lead indications, contraindica-ions, and management of biventricular malfunctions andnteractions, as well as postoperative complications. It haseen advocated that physicians training in congestive heartailure/transplantation could pursue an additional year ofraining to achieve Level 2 and Level 3 competency inmplantable devices by meeting all of the above COCATSraining requirements (19,20). An alternate pathway forraining in ICD implantation has been established for amall, finite group of physicians who have completedellowship training and have been high-volume pacemakermplanters for three or more years (20). It is recommendedhat Level 3 fellowship training for ICD implantationollows the above COCATS requirements.

VALUATION, COMPETENCE, AND PRIVILEGES

he program director should maintain adequate records ofach individual’s training experiences and performance ofarious procedures for appropriate documentation for Level 1,evel 2, and Level 3. The trainees should also maintain

ecords of participation in the form of a logbook containinglinical information, procedure performed, and outcome ofrocedures, including any complications encountered.The ACC, AHA, and HRS have formulated a clinical

ompetence statement on invasive electrophysiology studies,atheter ablation, and cardioversion (17). Self-assessmentrograms and competence examinations in electrocardiog-aphy are available through the ACC and other organiza-ions. Training directors and trainees are encouraged totilize these resources.The ACGME has published the essential components ofspecialized program for training in clinical cardiac elec-

rophysiology. The ABIM provides a special examination
or additional certification in clinical cardiac electrophysiol-

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gy. Information concerning the training requirements fordmission to the examination can be obtained from theBIM; such requirements include an additional year of

raining in an ACGME-accredited electrophysiology pro-ram. The HRS also has a written examination of specialompetence in device therapy, but it does not provide certifi-ation (21). Subsequent privileges to perform invasive proce-ures should be granted primarily on the basis of the technicalxpertise acquired in the training program, the documentedraining, and the recommendations of the directors oflectrophysiology/pacing programs.his is a revision of the 2002 document that was written byerald V. Naccarelli, MD, FACC, Jamie B. Conti, MD,ACC, John P. DiMarco, MD, FACC, and Philip T. Sager,D, FACC.

doi:10.1016/j.jacc.2005.12.028

EFERENCES

1. Josephson ME, Maloney JD, Barold SS, et al. Guidelines for trainingin adult cardiovascular medicine: Core Cardiology Training Sympo-sium (COCATS): Task Force 6: training in specialized electrophysi-ology, cardiac pacing and arrhythmia management. J Am Coll Cardiol1995;25:23–6.

2. Flowers NC, Abildskov JA, Armstrong WF, et al. ACC policystatement: recommended guidelines for training in adult clinicalcardiac electrophysiology: Electrophysiology/ElectrocardiographySubcommittee, American College of Cardiology. J Am Coll Cardiol1991;18:637–40.

3. Zipes DP, DiMarco JP, Gillette PC, et al. Guidelines for clinicalintracardiac electrophysiological and catheter ablation procedures: areport of the American College of Cardiology/American Heart Asso-ciation Task Force on Practice Guidelines (Committee on ClinicalIntracardiac Electrophysiologic and Catheter Ablation Procedures),developed in collaboration with the North American Society of Pacingand Electrophysiology. J Am Coll Cardiol 1995;26:555–73.

4. Naccarelli GV, Conti JB, DiMarco JP, Sager PT. Task force 6:training in specialized electrophysiology, cardiac pacing and arrhyth-mia management. Available at: http://www.acc.org/clinical/training/cocats2.pdf. Accessed January 1, 2006.

5. Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE2002 guideline update for implantation of cardiac pacemakers andantiarrhythmia devices: a report of the American College of Cardiol-ogy/American Heart Association/Task Force on Practice Guidelines(ACC/AHA/NASPE Committee to Update the 1998 Pacemaker

St. Jude Medical

6. Hayes DL, Naccarelli GV, Furman S, et al. NASPE policy statement:NASPE training requirements for cardiac implantable electronicdevices (CIED). Selection, implantation and follow-up. Pacing ClinElectrophysiol 2003;26:1556–62.

7. Curtis AB, Langberg JJ, Tracy CM. Clinical competency statement:implantation and follow up of cardioverter defibrillators. J CardiovascElectrophysiol 2001;12:280–4.

8. Winters SL, Packer DL, Marchlinski FE, et al. Consensus statementon indications, guidelines for use, and recommendations for follow-upof implantable cardioverter defibrillators. Pacing Clin Electrophysiol2001;24:262–9.

9. Scheinman MM. Catheter ablation for cardiac arrhythmias, personnel,and facilities: North American Society of Pacing and Electrophysiol-ogy Ad Hoc Committee on Catheter Ablation. Pacing Clin Electro-physiol 1992;15:715–21.

0. American College of Cardiology Cardiovascular Technology AssessmentCommittee. Catheter ablation for cardiac arrhythmias: clinical applica-tions, personnel and facilities. J Am Coll Cardiol 1994;24:828–33.

1. Scheinman M, Akhtar M, Brugada P, et al. Teaching objectives forfellowship programs in clinical electrophysiology. Pacing Clin Elec-trophysiol 1988;11:989–96.

2. Mitchell LB, Dorian P, Gillis A, Kerr C, Klein G, Talajic M.Standards for training in adult clinical cardiac electrophysiology:Canadian Cardiovascular Society Committee. Can J Cardiol 1996;12:476–80.

3. Accreditation Council for Graduate Medical Education. ProgramRequirements for Residency Programs in Clinical Cardiac Electro-physiology. Available at: http://www.acgme.org.

4. Zipes DP, Downing SM, Kangilaski R, Norcini JJ, Jr. The first cardiacelectrophysiology examination for added qualifications: American Boardof Internal Medicine. Pacing Clin Electrophysiol 1994;17:1327–31.

5. Clinical competence in elective direct current (DC) cardioversion: astatement for physicians from the ACP/ACC/AHA Task Force onClinical Privileges in Cardiology. J Am Coll Cardiol 1993;22:336–9.

6. Clinical competence in invasive cardiac electrophysiological studies:ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology.J Am Coll Cardiol 1994;23:1258–61.

7. Tracy CM, Akhtar M, DiMarco JP, Packer DL, Weitz HH. AmericanCollege of Cardiology/American Heart Association clinical competencestatement on invasive electrophysiology studies, catheter ablation, andcardioversion: a report of the American College of Cardiology/AmericanHeart Association/American College of Physicians—American Societyof Internal Medicine Task Force on Clinical Competence. J Am CollCardiol 2000;36:1725–36.

8. Wilkoff BL, Byrd CL, Love C. NASPE guidelines for lead extraction.Pacing Clin Electrophysiol 2000;23:544–51.

9. Naccarelli GV. Does it make sense to train plumbers as electricians?J Am Coll Cardiol 2004;44:1358–60.

0. Curtis AB, Ellenbogen KA, Hammill SC, et al. Clinical competencystatement: training pathways for implantation of cardioverter defibrillatorsand cardiac resynchronization devices. Heart Rhythm 2004;3:371–5.

1. Furman S, Bilitch M. NASPExAM. Pacing Clin Electrophysiol
Guidelines). Circulation 2002;106:2145–61. 1987;10:278–80.
PPENDIX 1. Author Relationships With Industry for the ACCF 2006 Update for Training in Adultardiovascular Medicine—Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, andrrhythmia Management


GrantScientific

Advisory BoardSpeakers’

BureauSteering

Committee Stock Holder Other

r. Jamie B. Conti None Medtronic,Inc.

Guidant Corp.St. Jude

Medtronic, Inc.St. Jude

None None None None

r. John P. DiMarco NovartisGuidantMedtronic

GuidantSanofi-Aventis

None MedtronicSt. Jude Medical

None None None



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BureauSteering

Committee Stock Holder Other

r. Gerald V. Naccarelli GuidantMedtronicSanofi-AventisWyeth-AyerstBoehringer-

IngelheimPfizerAstra-ZenecaGlaxo-Smith-

Kline

GuidantMedtronicSanofi-AventisWyeth-AyerstBoehringer-

Ingelheim


r. Cynthia M. Tracy None Medtronic,Inc.

Guidant Corp.



PPENDIX 2. External Peer Reviewer Relationships With Industry for the ACCF 2006 Update for Trainingn Adult Cardiovascular Medicine—Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing,nd Arrhythmia Management*


ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. Loren D.Berenbom

Board of GovernorsReviewer

Medtronic None None None None None MedtronicGuidantSt. JudeMedical–

UnderwriteEP fellowship

r. Peng-Sheng Chen

OrganizationalReviewer–HeartRhythm Society

None None None None None None MedtronicGuidantSt. Jude–

Donationof ICDand pacemakerfor researchin animallaboratories

r. Leonard S.Dreifus

Content Reviewer–ACCFElectrophysiologyCommittee


r. BengtHerweg

OrganizationalReviewer–HeartRhythm Society


r. AlanKadish

Content Reviewer–IndividualReview

St. JudeMedical

Lifewatch

St. JudeMedical

MedtronicGuidant


r. Bradley P.Knight


GuidantMedtronicCardioOptics

GuidantMedtronicCardioOptics

CardioOptics GuidantMedtronic

None None None

r. PeterKowey




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910 Pohost et al. JACC Vol. 47, No. 4, 2006Task Force 12: Training in Advanced Cardiovascular Imaging (CMR) February 21, 2006:910–4



ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. Bruce D.Lindsay



r. MichaelMirro

ACC OfficialReviewer–Board ofTrustees

CambridgeHeart

Life CorMedical

InformaticsEngineering

Astra-ZenecaMetronic

None Astra-Zeneca

MedtronicNovartisPfizer

None CambridgeHeart

Life CorMedtronicMedical

InformaticsEngineering

Pfizer

None

r. AndreaRusso


None GuidantMedtronicSt. Jude

Medical

None GuidantMedtronicSt. Jude

Medical

None None None

his table represents the relevant relationships of peer reviewers with industry to this topic that were disclosed at the time of peer review of this guideline. It does not necessarilyeflect relationships with industry at the time of publication. *Participation in the peer review process does not imply endorsement of the document. †Names are listed inlphabetical order.

ask Force 12: Training in Advanced Cardiovascularmaging (Cardiovascular Magnetic Resonance [CMR])ndorsed by the Society for Cardiovascular Magnetic Resonanceerald M. Pohost, MD, FACC, Chairaymond J. Kim, MD, FACC, Christopher M. Kramer, MD, FACC,
arren J. Manning, MD, FACC (Society for Cardiovascular Magnetic Resonance Representative)
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ardiovascular magnetic resonance (CMR) (Table 1), onef the newest cardiovascular imaging modalities, providesseful, often unique information with which all cardiologistshould be conversant. Training in CMR for cardiologyellows should be divided into three levels.

RAINING LEVELS

Level 1—General training (1 month) to provide theardiovascular trainee with a working knowledge of CMRethods and diagnostic utility.Level 2—Specialized training (at least 3 months) de-

igned to provide fellows with the skills necessary tondependently interpret CMR imaging studies.

Level 3—Advanced training for those who ultimatelyish to be responsible for the operation of a CMR labora-

ory. Level 3 criteria must include appropriate levels ofatient care, teaching, and research.

VERVIEW OF CMR TRAINING

ll cardiovascular medicine trainees should be taught the
asic types of CMR studies and their indications. Mentored l
nterpretation of CMR studies should be coupled withomparison and integration of test results with other rele-ant clinical and laboratory data. A mentor is an individualith the equivalent of Level 3 CMR training. This trainingenerally should be acquired through the Accreditationouncil for Graduate Medical Education—an approved

ardiology or radiology program with expertise in CMR andnder the aegis of a Level 3-qualified mentor in a laboratoryccredited by an organization such as the Intersocietalommission on the Accreditation of MR Laboratories

ICAMRL). Occasionally, a Level 3 qualified mentor willot be available in the institution housing the generalellowship program, but is available at a nearby non-cademic but medical center accredited for CMR by anrganization such as the ICAMRL. Under these circum-tances it is acceptable to place the trainee(s) at such aedical center for Level 1 to Level 3 training. The CMR

raining center and the trainee should maintain a logbook orther specific records to document the trainee’s case reviewnd the didactic hours in which the trainee has participated.

The depth of knowledge should increase with increasing
evels of training. In the case of the Level 3 trainee,

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911JACC Vol. 47, No. 4, 2006 Pohost et al.February 21, 2006:910–4 Task Force 12: Training in Advanced Cardiovascular Imaging (CMR)

pecialized training and, for academic trainees, researchhould be offered as a part of an established training programTable 2).

EVEL 1: GENERAL TRAINING (1-MONTH MINIMUM)

he trainee should have exposure to the methods and theultiple applications of CMR for a period of not less

han 1 month or its equivalent when interwoven withther training activities. This experience should provideasic background knowledge in CMR sufficient for theractice of adult cardiology and referral for CMR, but notor the practice/independent clinical interpretation ofMR. As a practical matter, many fellowship programs

n cardiovascular medicine may not be able to fulfillMR training. In these instances, fellows should be

ncouraged to obtain experience in an alternate programith appropriate training and accreditation in the per-

ormance of CMR studies.

idactic Activities

nterpretation of CMR studies. During their 1-month ofraining, trainees should actively participate in daily CMRtudy interpretation under the direction of a Level 2- orevel 3-trained CMR physician-mentor. For all studies inhich angiographic, echocardiographic, radionuclide, com-uted tomography, or hemodynamic data are available, suchnformation should be correlated with CMR studies. Stud-

able 1. Classification of CMR Procedures

. Standard CMR procedures, including:a. Tomographic still-frame CMR for morphology using “bright” and/

or “dark blood” methods with and/or without a paramagneticcontrast agent

b. Cine and other approaches to CMR for assessment of ventricularfunction

c. Magnetic resonance angiography and cine CMR of the greatvessels, anomalous coronary arteries, and coronary artery bypassgrafts

d. Delayed contrast-enhanced CMR imaging for myocardialinfarction, scar, intraventricular thrombus and microvascularobstruction (associated with MI) and viability assessment andvisualization of other causes of abnormal myocardial interstitium

e. First-pass CMR imaging (with vasodilator infusion) or cine CMRimaging with stress (with inotropic agent) for myocardial perfusionevaluation and ischemia detection

f. Phase-contrast velocity mapping for blood flow quantification forshunt sizing and determination of regurgitation and stenosis

g. Peripheral MR angiography. Less common procedures, including:a. Myocardial tagging (approach unique to CMR that allows more

detailed evaluation of intramural and transmural myocardialfunction than ventriculography alone and for evaluation ofpericardial disease)

b. MR angiography of the native coronary arteriesc. MR spectroscopy using 31P (to assess “high-energy phosphate

metabolism”) or other nuclei

MR � cardiovascular magnetic resonance; MI � myocardial infarction; MR �agnetic resonance.

es should include the range of procedures listed in Table 1. C

xperience in interpretation (a minimum of 50 cases) maynclude studies from an established CMR teaching file.

Lectures and self-study in CMR. This component shouldonsist of lectures on the basic aspects of CMR and paralleleading material of selected articles, digital training pro-rams, or CMR text. The lectures and reading shouldrovide the fellow with an understanding of CMR applica-ions. Specificity, sensitivity, diagnostic accuracy, utility inssessing prognosis and use of interventions, costs, artifacts,ndications, contraindications, and pitfalls must be includedor each cardiovascular diagnostic subset. Such informationould be effectively transmitted within a weekly non-invasive orlinical teaching conference during which CMR data areresented.A basic understanding of magnetic resonance physics

hould be provided, including the following: 1) the physicsf magnetic resonance as it relates to image intensity andontrast, including flow, T1 (spin-lattice relaxation time),2 (spin-spin relaxation time) and contrast agents;) sources of artifacts, including motion, arrhythmias, andetal objects; contrast agent side effects; 3) safety of devices

n the CMR environment; and 4) general post-processingools and analyses.

ands-On Experience

ands-on experience is not necessary for Level 1.

EVEL 2: SPECIALIZEDRAINING (AT LEAST 3 MONTHS)

raining for Level 2 should begin with the CMR experienceutlined in Level 1. Level 2 is for those trainees who wisho practice the specialty of CMR, including independentnterpretation of CMR studies. Level 2 trainees must havet least 3 months of dedicated CMR training (where 1onth is defined as 4 weeks and a week is defined as 35 h),

ncluding the basic elements listed in the following text. Therainee would be expected to become familiar with theMR techniques listed in Table 1.

ackground

n addition to Level 1 training, understanding of CMRhysics should be more advanced (see the following text).

able 2. Components of CMR Training

1. Didactic activitiesa. Lectures (it will be necessary in learning the physical principles and

in case interpretation to derive such information from relevantlectures–no more than 5% of the cases)

b. Self-study (it is possible to use cases from teaching files, journals,textbooks, or electronic/on-line courses. Such self-study cases needto be well documented in the trainee’s records and should notcomprise any more than 50% of the cases studied)

2. Independent interpretation of CMR cases (performed in thementoring CMR laboratory)

3. Participation in CMR case study interpretation4. “Hands-on” CMR experience

MR � cardiovascular magnetic resonance.

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nterpretation of CMR studies. During their 3 or moreonths of experience, trainees should actively participate

n daily CMR study interpretation under the direction ofLevel 2 or Level 3 (preferred) CMR-qualified physi-

ian. For all studies in which other cardiac imaging datare available, such information should be correlated withMR data. The trainee should interpret at least 150MR examinations during this training period, including0 for which the trainee is present during the scan, ideallys the primary operator and is the primary interpreter. Upo 50 of the 100 examinations for which the trainee is nothe primary interpreter can be derived from establishedeaching files, journals, and/or textbooks or electronic/n-line courses. Careful documentation of all case mate-ial and the details of the way in which the case waserived is essential.ectures and self-study in CMR. Course work would

nclude the components for Level 1 training but also shouldnclude more advanced lectures and reading materials. Thisork, with parallel reading, should continue for the dura-

ion of the traineeship. Course work should include theollowing:

. Physics: trainees should receive didactic lectures from aCMR-trained physician and/or physicist on the basicphysics of magnetic resonance in general and CMR inparticular. The content should include the same materi-als as in Level 1 (basic) plus lectures with supportivereading on the following topics:a. Image formation, including k-space, gradient echo,

spin echo, fast spin echo, echo planar, spiral, steady-state free precession (SSFP), and parallel imaging.

b. Specialized imaging sequences, including flow andmotion, phase imaging, time of flight, contrast agents,and radiofrequency tagging.

c. Hardware components, including the elements of gradi-ent coil design, receiver coils, and digital sampling.

. Applications, interpretation, indications, and contraindi-cations: Level 2 didactic activities should include anunderstanding of the sensitivity, specificity, accuracy,utility, costs, acquisition approaches, and disadvantagesof all of the contemporary techniques in CMR. Thefollowing techniques should be covered in the didacticprogram:a. Imaging of structure and tissue characterization (T1, T2,

spin echo, gradient echo, SSFP, and fat suppression).b. Imaging of function (cine and tagged cine magnetic

resonance including SSFP imaging).c. Volumetric imaging of mass, biventricular volumes,

and ejection fraction (using cine magnetic resonanceimaging).

d. Flow imaging (e.g., velocity-encoded techniques).e. Imaging of myocardial infarction, scarring, and viability

assessment (delayed contrast-enhancement imaging).t

f. Pharmacologic stress-testing with evaluation of ven-tricular function and/or first-pass perfusion using acontrast agent.

g. Magnetic resonance angiography (vascular).h. Electrocardiogram and peripheral pulse gating and trig-

gering including timing of image acquisition within theR-R interval, motion artifacts and their effects on CMRimages; respiratory motion suppression methods (e.g.,breath-holding and navigators).

i. Magnetic resonance spectroscopy methods (e.g., depthresolved surface coil spectroscopy or DRESS).

j. Cardiovascular magnetic resonance image analysis andpost-processing tools.

k. Contraindications for CMR study.l. Incidental findings suggesting pathology outside of

the cardiovascular system.

valuation

he person responsible for the CMR training program muste responsible for assessing the competence of the CMRrainee at the completion of the program. This is accom-lished by examining the ability of the trainee in thenderstanding of the acquisition methods and the interac-ive role of the operator during the performance of studiesnd in the interpretation of the data acquired during dailyeading sessions. This may be supplemented by formalesting.

EVEL 3: ADVANCED TRAINING12 MONTHS OR MORE FOR THOSENTERESTED IN RUNNING AN ACADEMIC PROGRAM)

evel 3 CMR training represents the highest level ofraining and would enable the trainee to pursue a clinical or

able 3. Summary of Requirements for Each Level ofMR Training

LevelDuration of

Training (Months) Number of Cases

1 1 50� Mentored interpretations (by aLevel 2- or 3-trained physician)

2 3 to 6* 150� Mentored interpretations (by acertified Level 2- or Level 3-[preferred] qualified CMRphysician) including at least 50 asprimary interpreter (and operator,if possible)†

3 12 or more monthsof training*

300� Mentored interpretations (by aLevel 3-qualified CMR physician)including 100� as primaryinterpreter (and operator, ifpossible)†

This time represents the number of months spent reviewing cases, and interpreting,erforming, and learning about CMR, and need not be a consecutive block of time,ut at least 50% of the time should represent mentored laboratory experience. †Thease recommendations may include studies from an established teaching file, previousMR cases, journals, and/or textbook or electronic/on-line courses/continuingedical education. No less than 50% of the cases should be from those performed at

he mentoring CMR laboratory.CMR � cardiovascular magnetic resonance.

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913JACC Vol. 47, No. 4, 2006 Pohost et al.February 21, 2006:910–4 Task Force 12: Training in Advanced Cardiovascular Imaging (CMR)

cademic career in CMR and to direct a CMR laboratory.evel 3 training in CMR could be obtained as part of a 3-r 4-year cardiology fellowship. In addition to the recom-endation for Level 2, the Level 3/academic program

hould include active participation in ongoing basic orlinical CMR research or both, with individual responsibil-ty for a specific portion of that research. Focused researchork with publication of one or more manuscripts is an

mportant part of Level 3 training. Level 3 training must beerformed under the guidance of at least one Level-trained CMR physician.In parallel with research activities, the Level 3 traineeust participate in clinical imaging that should include

upervised interpretation of at least 300 CMR cases. Therainee must be physically present and involved in thecquisition and the primary interpretation of at least 100MR cases. In the remaining 200 cases, the trainee should

eview at least 100 of these with the Level 3 mentor at theraining facility. The remaining cases can be derived fromstablished teaching files, journals, and/or textbooks orlectronic/on-line courses. Careful documentation of allase material and the details of the way in which the caseas derived are essential.Knowledge of magnetic resonance physics must be more

. Analysis of why certain specialized imaging sequencesare applicable for specific clinical protocols, includingimaging of heart function, coronary arteries, perfusion,delayed enhancement, and peripheral arteries.

. Basic understanding of the clinically applicable spectro-scopic methods.

. The essentials of data collection, including capturing ofdigital data, the maintenance of accurate databases andrecords, signal processing, and the approach for obtain-ing quantitative data.

valuation

valuation should be similar to that of Level 2.

ummary of Recommendations

he overall requirements for training in CMR are summa-ized in Table 3.

his is an update of the 2002 document that was written byerald M. Pohost, MD, FACC, Raymond J. Kim, MD,ACC, Christopher M. Kramer, MD, FACC, and Nathanieleichek, MD, FACC.

dvanced than Level 2 and include the following: doi:10.1016/j.jacc.2005.12.029

PPENDIX 1. Author Relationships With Industry for the ACCF 2006 Update for Training in Adultardiovascular Medicine—Task Force 12: Advanced Cardiovascular Imaging (Cardiovascular Magneticesonance)

Name Consultant Research Grant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. Raymond J. Kim Mallinckrodt None None None None None Siemens-EducationalGrant

r. Christopher M. Kramer None FujisawaNovartis

None GE Healthcare None None Siemens,Merck-Researchmaterialssupport

r. Warren J. Manning None None None None None None None

r. Gerald M. Pohost None None None TakedaPharmaceuticals

None None None


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PPENDIX 2. External Peer Reviewer Relationships With Industry for the ACCF 2006 Update for Trainingn Adult Cardiovascular Medicine-Task Force 12: Training in Advanced Cardiovascular Imaging (Cardiac

agnetic Resonance)*


ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauStock

Holder


Content Reviewer–ACCFCardiovascularImaging Committee

Tarctegen None None None None

r. John McB.Hodgson

OrganizationalReviewer–Societyfor CardiovascularAngiography andInterventions

Volcano GE Medical GE Medical Volcano TechnologySolutionsGroup

r. Spencer King,III

Content Reviewer–ACCF CardiacCatheterization andInterventionCommittee


r. Edward T.Martin


Guidant Guidant Guidant GE Medical None

r. Patrick O’Gara ACC OfficialReviewer–Boardof Trustees

BostonScientificCorp.

None None None None

r. Dudley Pennell Content Reviewer–Individual Review

SiemensBMSNovartis

None Preventicum None CardiovascularImagingSolutions

r. NathanielReichek



r. Charanjit S.Rihal

Content Reviewer–ACCF CardiacCatheterizationand InterventionCommittee


r. Thomas L.Rosamond

ACC OfficialReviewer–Boardof Governors


r. Carlos Ruiz Content Reviewer–ACCF CardiacCatheterizationand InterventionCommittee


r. RobertSchwartz

OrganizationalReviewer–Societyof CardiovascularAngiography &Intervention



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915JACC Vol. 47, No. 4, 2006 Budoff et al.February 21, 2006:915–20 Task Force 12: Training in Advanced Cardiovascular Imaging (CT)

ask Force 12: Training in Advancedardiovascular Imaging (Computed Tomography)

ndorsed by the American Society of Nuclear Cardiology, Society forardiovascular Angiography and Interventions, Society of Atherosclerosis

maging and Prevention, and Society of Cardiovascular Computed Tomographyatthew J. Budoff, MD, FACC, FAHA, Chair

tephan Achenbach, MD (Society of Cardiovascular Computed Tomography Representative),ahi Fayad, PHD (Society of Atherosclerosis Imaging and Prevention Representative),aniel S. Berman, MD, FACC, Michael Poon, MD, FACC, Allen J. Taylor, MD, FACC, FAHA,arry F. Uretsky, MD, FACC (Society for Cardiovascular Angiography and Interventions Representative),
im Allan Williams, MD, FACC (American Society of Nuclear Cardiology Representative)
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omputed tomography (CT) is one of the most rapidlyvolving techniques for assessing cardiovascular anatomy.he complex nature of the imaging devices and anatomy

s well as the rapidly advancing uses of these modalitiesequires the trainee to be introduced to this modality.linical application of CT encompasses non-contrast

coronary calcium evaluation), contrast (CT angiographynd function), and hybrid studies (combining nuclearardiac scanning with CT). Computed tomography, likenvasive catheterization, provides information concerningardiovascular anatomy and function (i.e., ejection frac-ion). Hybrid devices are rapidly evolving to incorporatetate-of-the-art, high-speed multi-detector computed to-ography (MDCT) technology, along with the latest

ositron emission tomography, and single-photon emis-ion computed tomography (SPECT) detector systems.urrent hybrid systems (MDCT plus nuclear) provide

ttenuation correction for SPECT, thereby further im-roving the diagnostic accuracy of more traditional ra-ionuclide techniques.It should be noted that the guidelines for fellows

n training outlined here and those for physicians inractice previously published have slightly different tar-ets for time and experience. The fellows-in-training arexpected to gain exposure to CT throughout their train-ng, incorporating the results with echocardiography,uclear cardiology, cardiovascular magnetic resonanceCMR), and cardiac catheterization when appropriate.hysicians-in-practice who are being exposed to cardiacT for the first time will most likely not have this

omprehensive approach. Guidelines for practicing phy-icians are published by the American College of Cardi-logy/American Heart Association Task Force on Clin-cal Competence in CT and MR (1). Fellowship trainingn CT should include instruction in the basic aspects, butnly those fellows who go beyond the basic level arerained sufficiently for independent interpretation of CTtudies. Every trainee should be educated in the use of
T and in cardiovascular anatomy, physiology, and a
athophysiology, as well as physics of CT and radiationeneration and exposure. As many cardiovascular com-uted tomographic (CCT) studies are done before andfter intravenous administration of iodinated contrast, ahorough understanding of contrast injection methods,dverse events and their treatments, and contrast kineticsn patients will be required. In particular, knowledge iseeded in the methods of contrast-enhanced imaging ofhe pericardium, right ventricle, right atrium, and supe-ior and inferior vena cavae, as well as imaging of the lefteart, surrounding great vessels, and the centralirculation.

By the end of the fellowship, trainees should have beenxposed to cardiac CT studies, both in interpretation anderformance. It is currently recognized that many programsight not have availability of CCT, and options should beade available to obtain training at a different facility if the

rimary program cannot accommodate. The trainee shouldaster the relation between the results of the CT examina-

ion and findings of other cardiovascular tests, such asatheterization, nuclear cardiology, MR, and echocardiog-aphy. Every cardiology fellow should be exposed to and beamiliar with the technical performance, interpretation,trengths, and limitations of CT and its multiple clinicalpplications. It is recognized that CT is an evolving tech-ology in a rapid phase of development and improvement,ith an expanding list of clinical indications.For appropriate use of this technology, it is possible to

efine three levels of expertise (Table 1). All cardiologyellows must attain at least the first level of expertise. Thisntails understanding the basic principles, indications, ap-lications, and technical limitations of CT and the inter-elation of this technique with other diagnostic methods.his level will not qualify a trainee to perform CT or to

nterpret CT independently.Level 2 is defined as the minimum recommended training

or a trainee to independently perform and interpret CCT.third level of expertise would enable the trainee to direct

CT laboratory.

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916 Budoff et al. JACC Vol. 47, No. 4, 2006Task Force 12: Training in Advanced Cardiovascular Imaging (CT) February 21, 2006:915–20

ENERAL STANDARDS

he CT laboratory in which training is undertaken shoulde under the direct supervision of a full-time qualifiedirector (or directors) who has preferably achieved Level 3raining. Training guidelines in the present document arerimarily directed to trainees performing cardiac CT exam-nations in adult patients with acquired and congenital heartisease. Participation of additional full- or part-time faculty

s highly desirable because of the multiple applications ofT (i.e., attenuation correction of nuclear imaging, non-

ontrast and contrast studies, function, structure, and con-enital). The cardiac CT examination is an operator-ependent procedure in which it is possible to introduceonfounding artifacts or omit data of diagnostic importance.ands-on training is important, not to develop technical

xpertise in acquiring images but rather as a valuable aid toearn tomographic cardiac anatomy, integrate planar viewsnto a three-dimensional framework (non-planar andblique/multiplanar imaging), and understand the distinc-ion between reliable and unreliable data. Understandinghe source of the artifacts (breath-holding, gating, or ar-hythmias) present on the images is vital.

ONTENT OF THE TRAINING PROGRAM

lthough the number of studies and time intervals of trainingre given as guidelines, these numbers are less importanthan the depth of understanding and quality of the clinicalxperience. It is recommended that fellows keep a log docu-enting their involvement in CT studies, as well as their

xposure to appropriate continuing medical education hours.The recommendations for all levels of training in the

ollowing text represent a cumulative experience, and it isxpected that for many fellows the training will not beontinuous. A summary of the training requirements isiven in Table 1. For all Level 2 and 3 requirements, theinimum time in a CCT laboratory is 50% of the time

isted. The remaining time required can be garnered byupervised time, CT exposure in courses, case studies,D/DVD training, time at major medical meetings devoted

able 1. Requirements for CCT Study Performance andnterpretation to Achieve Level 1, 2, and 3 Clinical Competence

CumulativeDuration

of Training

Minimum Numberof Mentored

ExaminationsPresent During

Performance

Minimum Numberof Mentored

ExaminationsInterpreted

evel 1 1 month* — 50†evel 2 2 months* 35 150†evel 3 6 months* 100 300†

This represents cumulative time spent interpreting, performing and learning aboutCT, and need not be a consecutive block of time, but at least 50% of the time should

epresent supervised laboratory experience. In-lab training time is defined as ainimum of 35 h/week. †The caseload recommendations may include studies from

n established teaching file, previous CCT cases, journals and/or textbook orlectronic/on-line courses/continuing medical education.

CCT � cardiovascular computed tomography.

o performance of CCT, or other relevant educational p

raining activities to name a few examples. The caseloadecommendations may include studies from an establishedeaching file, previous CCT cases, electronic/online experi-nce, or courses.

evel 1 Training (1 Month,t Least 50 Examinations Interpreted)

evel 1 is defined as the minimal introductory training foramiliarity with CCT, but is not sufficient for independentnterpretation of CCT images. The individual should haventensive exposure to the methods and the multiple appli-ations of CCT for a period of at least 1 month. The timeommitment for training is defined as 35 h/week. Thishould provide a basic background in CCT for the practicef adult cardiology. During this cumulative 4-week experi-nce, individuals should have been actively involved in CCTnterpretation under the direction of a qualified (preferablyevel 3-trained) physician-mentor (1). There should be aentored interpretative experience of at least 50 cases for all

tudies in which other cardiovascular imaging methods arelso available as well as correlation with CCT findings andnterpretation. Mentored interpretive experience may in-lude studies from an established teaching file or previousCT cases and also includes the potential for CD/DVD

nd online training.For all levels of competence, it is expected that the

andidate will attend lectures on the basic concepts of CCTnd include parallel self-study reading material. A basicnderstanding of CCT should be achieved including: thehysics of CCT imaging, the basics of CCT scan perfor-ance, safety issues in CCT performance, side effects (and

heir treatment) of medications used currently includingeta-blockers and nitrates, post-processing methods, andhe basics of CCT interpretation as compared with otherardiovascular imaging modalities including echocardiogra-hy, nuclear cardiology, cardiac MR, and invasive cardiacnd peripheral X-ray angiography. Furthermore, auxiliaryardiac diagnostics should include recognition of ventricularypertrophy, dilation, valve pathologies such as mitraltenosis/annular and leaflet calcification, aortic valve pathol-gy (number of cusps), and calcification/aortic stenosis,ericardial disease, internal mammary arteries, and saphe-ous vein grafts.

evel 2 Training (2 Months ofraining and Interpretation of 50 Non-Contrastnd 150 Contrast Studies Total, of Which in 35 theellow is Present During Performance)

evel 2 is defined as the minimum recommended trainingor a physician to independently perform and interpretCT. To accomplish this, the fellow should devote an

dditional 1 month, or the equivalent, interpreting a mini-um of 150 contrast studies total. The non-contrast and

ontrast studies may be evaluated in the same patients. Ofhese, at least 35 cases should be performed with the fellow
resent under appropriate supervision. Competence at this

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evel implies that the fellow is sufficiently experienced tonterpret the CT examination accurately and independently.ontinued exposure to special CT procedures such asybrid studies with nuclear imaging and integration of

mages into electrophysiologic procedures is appropriateuring Level 2 training.Didactic studies should include advanced-lecture readingaterials and formal case presentations. These didactic

tudies should include information on the sensitivity, spec-ficity, accuracy, utility, costs, advantages, and disadvantagesf CCT as compared with other cardiovascular imagingodalities. Each fellow should receive documented training

rom a CCT mentor and/or physicist on the basic physics ofT in general and on CCT in particular. Lectures will

nclude discussions of anatomy, contrast administration andinetics, and the principles of three-dimensional imagingnd post-processing. The fellow should also receive trainingn principles of radiation protection, the hazards of radiationxposure to both patients and CT personnel, and appropri-te post-procedure patient monitoring.

A fellow with Level 2 and Level 3 training should demon-trate a clear understanding of the various types of CTcanners available for cardiovascular imaging (electron beamomography and MDCT) and understand, at a minimum,ommon issues related to imaging, post-processing, andcan interpretation including:

Indications and risk factors that might increase thelikelihood of adverse reactions to contrast mediaRadiation exposure factorsCT scan collimation (slice thickness)CT scan temporal resolution (scan time per slice)Table speed (pitch)Field of viewWindow and level view settingsAlgorithms used for reconstructionContrast mediaPresence and cause of artifactPost-processing techniques and image manipulation onwork stationsTotal radiation dose to the patient

ncidental Non-Cardiac Findings

uring a cardiac CT examination, the standard use of amall field of view (e.g., limited lung fields) precludes aomplete evaluation of the entire thorax. However, toddress the possibility that significant non-cardiac imagingndings (e.g., aortic disease, hilar adenopathy, large pulmo-ary nodules, and pulmonary emboli) might be present on aardiac CT scan, specific interpretation of the extra-cardiacelds should be performed. The patient and the referringhysician should understand that the focus of the cardiacT examination is the detection of cardiac disease, and the

can does not encompass the entire lung field. Regardinghe cardiovascular medicine specialist performing a cardiac
T, the American College of Cardiology recognizes and u
ndorses education and training of such individuals in theecognition of incidental scan findings in support of qualitymaging care of patients with cardiovascular disease. Theseases require referral to a specialist or a radiologist withxpertise in chest imaging. To this end, it is felt that Level

and Level 3 training should include the review of allardiac CT cases for non-cardiac findings. The review of50 cardiac CT cases for incidental findings should includehe review of a dedicated teaching file of 25 cardiac CTases featuring the presence of significant non-cardiac pa-hology. Furthermore, part of the core curricula for Level 2nd Level 3 should include specific lectures on non-cardiacT pathology.

evel 3 Training (Total 12 Monthsf Training, Inclusive of Level 1 andevel 2, 150 Additional Examinations)

evel 3 training represents the highest level of exposure/xpertise that would enable an individual to serve as a directorf an academic CCT section or director of an independentCT facility or clinic. This individual would be directly

esponsible for quality control and training of technologistsnd be a mentor to other physicians seeking such training.or a trainee desiring to direct a CT laboratory (Level 3), a

otal of 6 months of training devoted to CT is required, withn additional 6 months’ experience that can be obtainedoncurrently with training in other imaging modalities. Tottain Level 3, candidates should be involved with interpre-ation of at least 100 non-contrast and 300 contrast CCTxaminations. For at least 100 of these cases, the candidateust be physically present and be involved in the acquisition

nd interpretation of the case. At the discretion of theirector, increasing independence in interpretation andverreading of CT studies can be implemented.In addition to the recommendations for Level 1 and

evel 2 training, Level 3 training should include active andngoing participation in a basic research laboratory, clinicalesearch, or graduate medical teaching. Level 3 traininghould also include exposure to administrative aspects ofunning a CT laboratory and documented experience in CTesearch, as well as understanding of new and evolvingT and nuclear/CT technologies. To complete Level 3,

he trainee should fulfill all of the previously describedequirements and develop competence in performing andnterpreting special procedures, such as hybrid studies andlectrophysiologic studies (integration of CT images withuoroscopic images to provide enhanced visualization forblation).

raining for Physicians in Practice

t should be recognized how difficult it is to recreate thereadth and intensity of a training fellowship once an individ-
al has assumed the full-time responsibilities of a practice

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etting. For the practicing physician interested in obtainingquivalent training, please refer to the recent report of themerican College of Cardiology Foundation/American Heartssociation/American College of Physicians Task Force onlinical Competence on CT and MR (1).

EFERENCE

. Budoff MJ, Cohen MC, Garcia M, et al. ACC/AHA clinical compe-tence statement on cardiac imaging with computed tomography andmagnetic resonance. A report of the American College of Cardiology/American Heart Association/American College of Physicians Task

doi:10.1016/j.jacc.2005.12.030Force on Clinical Competence (ACC/AHA Committee on CardiacTomography). J Am Coll Cardiol 2005;46:383–402.

PPENDIX 1. Author Relationships With Industry for the ACCF 2006 Update for Training in Adultardiovascular Medicine—Task Force 12: Advanced Cardiovascular Imaging (Computed Tomography)


GrantScientific


BureauSteering

CommitteeStock

Holder Other

r. Stephan Achenbach None Siemens None None None None None

r. Daniel S. Berman Tyco-Mallincrodt

BMSAstellasGE Healthcare

SpectrumDynamics

None None SpectrumDynamics

Cedars-SinaiMedicalCenter–SoftwareRoyalites

r. Matthew J. Budoff None None None PfizerGE Healthcare

None None None

r. Marcello DiCarli None None None None None None None

r. Zahi Fayad None None None None None None None

r. Michael Poon None None Chase MedicalSiemensTeraRecon, Inc.

None None None None

r. Allen J. Taylor None Kos Pharm None Kos Pharm None None None

r. Barry F. Uretsky None None None None None None None

r. Kim AllanWilliams

King GE HealthcareBMSCVT

GE Healthcare GE HealthcareAstellas

None None None


PPENDIX 2. External Peer Reviewer Relationships With Industry for the ACCF 2006 Update for Trainingn Adult Cardiovascular Medicine—Task Force 12: Advanced Cardiovascular Imaging (Computedomography)*


ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. MazenAbu-Fadel

ContentReviewer–ACCFCardiacCatheterizationandInterventionCommittee


r. BruceBrundage

ContentReviewer–IndividualReview



A

D

D

D

D

D

D

D

D

D

D




ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other


ContentReviewer–ACCFCardiovascularImagingCommittee

Tarctegen None None None None None None

r. HarveyHecht


None PhilipsMedical


r. John McB.Hodgson

OrganizationalReviewer–Society forCardiovascularAngiographyandInterventions

Volcano GE Medical GEMedical

Volcano None TechnologySolutionsGroup

None

r. Ami E.Iskandrian

ContentReviewer–ACCFCardiovascularImagingCommittee

CVTherapeutics

InternationalAtomicEnergyAgency

AstellasPharma

MolecularInsightCorp.

GE MedicalCV TherapeuticsBMS

None None None None AcusphereInc.–BlindedReader

r. SpencerKing, III



r. Edward T.Martin


Guidant Guidant Guidant GEMedical

None None None

r. PatrickO’Gara

ACC OfficialReviewer–Board ofTrustees

BostonScientificCorp.

None None None None None None

r. PaoloRaggi

ContentReviewer–CardiovascularImagingCommittee

None PfizerGenzyme

None GenzymeAstra Zeneca

None None None

r. CharanjitS. Rihal



r. Thomas L.Rosamond

ACC OfficialReviewer–Board ofGovernors



A

D

D

D

Tra




ResearchGrant

ScientificAdvisory

BoardSpeakers’

BureauSteering

CommitteeStock

Holder Other

r. CarlosRuiz



r. John A.Rumberger



r. RobertSchwartz

OrganizationalReviewer–Society forCardiovascularAngiographyandInterventions



accf 2006 update for training in adult cardiovascular

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