COCATS 4 Task Force 3: Training in Electrocardiography, Ambulatory Electrocardiography, and Exercise Testing

1.1.1 Writing Committee Organization

The writing committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director, an early-career cardiologist, highly experienced members representing both academic and community-based practice settings, and physicians experienced in defining and applying training standards according to the core competencies structure promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were not relevant to the creation of this general cardiovascular training statement. Employment and affiliation details for the authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.

1.1.2 Document Development and Approval

The writing committee developed the document, approved it for review by individuals selected by the ACC, and then addressed the peer reviewers’ comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed the additional comments from the public to complete the document. The final document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Management Committee as well as ratified by the ACC Board of Trustees in March 2015. This document is considered current until the ACC Competency Management Committee revises or withdraws it.

2.1.1 Faculty

Faculty should include specialists skilled in ECG interpretation. This should include specialists in both clinical cardiac electrophysiology and cardiology. Faculty should be board-certified in cardiovascular diseases or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures.

2.1.2 Facilities

Facilities should provide adequate training in multiple clinical settings, including inpatient, outpatient, emergent, and invasive (catheterization and/or electrophysiology laboratory). Facilities should also be available for didactic teaching.

2.1.3 Equipment

Equipment should be sufficient to provide reliable and reproducible ECGs and should include computerized devices that record and store a graphic display and automatically generate a preliminary interpretation.

2.1.4 Ancillary Support

Ancillary support staff should be well trained and available to administer high-quality ECG testing and collect the appropriate data, preferably in an electronic format.

2.2.1 Didactic Program

Didactic instruction may take place in a variety of formats, including, but not limited to, lectures, conferences, journal clubs, grand rounds, clinical case presentations, and patient safety or quality improvement conferences. Fellows must be trained to interpret a large number of ECGs and review all interpretations with experienced faculty. Programs should encourage the trainee to interpret a majority of ECGs side by side with faculty for immediate review and feedback. Formal, correlative conferences in ECG are highly recommended as part of the fellowship curriculum and should be held regularly during training. In addition, the role of ECG in clinical practice should be thoroughly reviewed.

2.2.2 Clinical Experience

Training in ECG interpretation should include clinical correlation in patients from a wide range of clinical settings, such as intensive care units, emergency rooms, and pacemaker/defibrillator clinics, as well as exposure to all forms of clinically-encountered arrhythmias, normal variants, and electrocardiographic patterns associated with acquired and congenital heart disease. Trainees should be trained to review, edit, and amend ECGs generated by computerized systems that provide a preliminary interpretation.

2.2.3 Hands-On Experience

Hands-on experience is essential for training in ECG interpretation. Additionally, trainees are expected to acquire the technical skills necessary to competently perform and record high-quality, standard 12-lead ECG tracings.

2.3.1 Development and Evaluation of Core Competencies

Training and requirements for ECG and ambulatory ECG address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.

Table 1 delineates each of the 6 competency domains, as well as their associated curricular milestones for training in ECG and ambulatory ECG. The milestones indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. The table also describes examples of evaluation tools suitable for assessing competence in each domain.

2.3.2 Training Requirements

All trainees should achieve Level I training in ECG interpretation. Attainment of skills and competencies during the training program is paramount and must be emphasized. There is no established threshold number of studies that can serve as a training landmark; however, interpreting approximately 3,000 to 3,500 ECGs within 36 months should provide ample experience to acquire such competencies. This represents the procedural volume typically required to obtain competency, but the trainee must also demonstrate that competence is achieved, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for ECG interpretation or as a continuous experience through clinical rotations. The cardiovascular subspecialist should be familiar with nearly all clinically encountered arrhythmias (normal variants) and electrocardiographic patterns associated with acquired and congenital heart disease and those that may accompany high-level exercise and athletic conditioning (10). This knowledge should include an understanding of the physiological mechanisms for arrhythmias and ECG waveforms, rather than simple recognition of patterns. The trainee should understand the clinical implications, sensitivity, and specificity of the ECG. Training in ECG interpretation requires additional experience with interpreting complex arrhythmias and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices. As such rhythms can be quite complex, trainees should be able to recognize when to seek consultation and assistance from an experienced electrophysiologist. The ECG knowledge base is included in Appendixes 1 and 2, and contains minimum requirements for each trainee.

The trainee should also be familiar with the instrumentation necessary to acquire, process, and store ECGs in both analog and digital formats; understand the effect of acquisition rates and filter settings; and recognize electronic artifacts. In addition, they should be able to accurately measure basic ECG intervals in both analog and digital systems.

There is no Level II or III training in ECG. The interpretive skills for highly complex arrhythmia diagnosis, signal-averaged ECG interpretation, and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices would be acquired during specialized training in electrophysiology (see COCATS 4 Task Force 11 report).

3.1.1 Faculty

The trainee should participate in interpretation sessions with a staff cardiologist knowledgeable in the indications for the test, the techniques of recording, and the clinical significance and correlations of findings. Faculty should be board-certified in cardiovascular diseases or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures. If dedicated electrophysiology faculty are available, the trainee should take advantage of this knowledge for evaluating and managing complex arrhythmias. Faculty should be available to discuss individual cases and provide formal educational experiences.

3.1.2 Facilities

Cardiovascular departments (heart stations) should have staff and space available for collecting and organizing ambulatory ECG data, preferably using digital technology. These data should be readily accessible for faculty and fellows in a timely fashion. In addition, access to patients’ medical information, preferably via an electronic health record, is important to correlate findings with clinical status. The reviewer of the ambulatory ECG should be able to locate and communicate with the treating physician to convey critical information.

3.1.3 Equipment

The trainee should be familiar with the various devices that are available for both continuous and intermittent recording of cardiac rhythms (11). Trainees should understand how to place the equipment to collect cardiac monitoring data accurately.

3.1.4 Ancillary Support

Ancillary support should be available to administer ambulatory ECG testing and collect the appropriate data, preferably in an electronic format.

3.2.1 Didactic Program

A comprehensive educational program should be provided to trainees to complement hands-on interpretation of ambulatory ECG recordings. The training program shall include didactic lectures, interactive case presentations, and self-directed learning. The educational offerings for ambulatory ECG should be combined with teaching about ECG and other topics in electrophysiology. Over the course of cardiovascular fellowship training, trainees should understand how to interpret and report ambulatory ECG information and should be taught about advances in ECG technology and the importance of this type of testing in evaluating patients with cardiovascular disease.

3.2.2 Clinical Experience

Trainees should be exposed to a wide array of ambulatory ECG monitors from a mix of patient populations, including those with complex rhythm disturbances and congenital and acquired structural heart disease. Trainees should be responsible for analyzing and interpreting all aspects of the ambulatory ECG study. When appropriate, the trainee should have knowledge of the patient’s medical background and rationale for testing. An experienced attending cardiologist in ambulatory ECG should oversee the trainee and be responsible for evaluating and documenting the trainee’s progress and skill level. In addition, expert consultation should be sought for complex arrhythmias from faculty with advanced training in electrophysiology, if available.

3.2.3 Hands-On Experience

Trainees should be provided with the opportunity to learn all aspects of ambulatory ECG monitoring, including understanding available technologies, advising the patient, ordering the test, placing the monitor on or in the patient, and downloading the information. Analysis and interpretation of the data are critical to developing competency in this area. Trainees should also understand how to relay critical findings to the patients and other healthcare team members. Each of these steps should be overseen by an attending cardiologist comfortable with this testing modality.

3.3.1 Training Requirements

Attainment of skills and competencies during the training program is paramount and must be emphasized. There is no established threshold number of studies that can serve as a training landmark. However, interpreting approximately 100 to 200 ambulatory ECGs within 36 months should provide ample experience to acquire such competencies. This volume of procedures is typically required to obtain competency, but there must also be demonstration of achievement of competence, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for interpretation of ambulatory ECGs or as a continuous experience through clinical rotations. Trainees should be exposed to both full-disclosure (complete printout) and computer-assisted ambulatory ECG systems. In addition, trainees should be exposed to transtelephonic and event-recorder devices for prolonged ambulatory ECG. Furthermore, trainees should be exposed to recordings such as artifact, pacemaker, and implantable cardioverter-defibrillator patterns; heart rate variability studies; and repolarization abnormalities. Trainees should demonstrate knowledge of the operation and limitations of a variety of types of ambulatory ECG instrumentation. In addition, all trainees should be skilled in interpreting in-hospital telemetry ECGs. Trainees should understand the indications and limitations of testing from structured training by experienced cardiologists with specific expertise in ambulatory ECG. Such training will provide knowledge to satisfy clinical competence in ambulatory ECG as indicated by the ACC/AHA/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence (8).

There is no Level II or III training in ambulatory ECG. The interpretive skills for highly complex arrhythmia diagnosis, insertion and management of implantable loop recorders, and those normal and abnormal rhythms associated with pacemaker and implantable defibrillator devices would be acquired during specialized training in electrophysiology (see COCATS 4 Task Force 11 report).

4.1.1 Faculty

Faculty should be effective teachers who are experts in the clinical use and interpretation of exercise ECG testing and who perform these tests on a regular basis. Such faculty should be supervised by the physician medical director of the exercise testing laboratory, such that the specifics of exercise test performance, protocols, and interpretation are consistent with the laboratory’s policies and standards. The faculty should be board-certified in cardiovascular disease or possess equivalent qualifications. A physician is considered to have equivalent qualifications if he or she trained in a similar environment for a similar duration of time and performed the required number of procedures.

4.1.2 Facilities

The laboratory should regularly perform exercise tests that involve a broad spectrum of both inpatients and outpatients with a variety of known and suspected cardiovascular disorders. Specific standards regarding the exercise testing environment are outlined by the AHA (14).

4.1.3 Equipment

The laboratory should contain exercise testing equipment for testing and monitoring, as well as emergency medications and equipment as outlined by the AHA (14).

4.1.4 Ancillary Support

The exercise testing laboratory staff generally consists of a variety of personnel that may include exercise physiologists, nurses, nurse practitioners, physicians’ assistants, and medical technicians. These individuals often perform several duties, including assessing and preparing patients for the test; conducting the technical aspects of the test, including protocol selection and patient monitoring; and assisting the physician staff with patient management and medical emergencies should the need arise. Appropriate training requirements and information about the cognitive and performance skills necessary to competently supervise exercise tests are available in published guidelines (8,14).

4.2.1 Didactic Program

Didactic instruction may take place in a variety of formats, including, but not limited to, individual instruction during exercise test performance and interpretation sessions, lectures, conferences, journal clubs, grand rounds, and clinical case and correlative conferences. In addition, self-learning—through required reading material that includes relevant guidelines, textbooks, seminal papers, and emerging literature regarding exercise testing—is essential. Such learning material should be provided, updated, and monitored by the exercise laboratory director or other faculty.

4.2.2 Clinical Experience

The trainee must become proficient in the interpretation of commonly used measurements available from the exercise test that are performed in a wide variety of patients with various cardiovascular conditions and other comorbidities. The trainee must acquire a working knowledge of cardiovascular exercise physiology and a keen understanding of appropriate and inappropriate physiological responses to exercise. Understanding all of the technical aspects of testing is essential to ensure proper test performance and interpretation of results. The trainee must be thoroughly familiar with methods used in determining exercise capacity and its importance in prognostic evaluation and activity prescription. The trainee should become proficient in integrating data such as hemodynamic measurements, exercise ECG analyses, and non–ST-segment variables in both the diagnostic and prognostic assessment of the patient. This training will provide knowledge to satisfy clinical competence in exercise testing, as indicated by the ACC/AHA/American College of Physicians–American Society of Internal Medicine Task Force on Clinical Competence (15).

4.2.3 Hands-On Experience

The training program should be structured so that the trainee is guided in the laboratory by a specially trained exercise professional until the trainee has become proficient at conducting and personally monitoring exercise tests under a variety of clinical circumstances. The trainee must be given the responsibility of initially interpreting all phases of the exercise study, as well as providing that detailed interpretation to, and reviewing it with, the attending cardiologist who is responsible and experienced in exercise testing.

4.3.1 Development and Evaluation of Core Competencies

The training and requirements for exercise testing address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.

Table 2 delineates each of the 6 competency domains, as well as their associated curricular milestones for training in exercise–ECG testing. The milestones indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Recognizing that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may vary as well. Level I competencies may be achieved at earlier or later time points. The table also describes examples of evaluation tools suitable for assessment of competence in each domain.

4.3.2 Training Requirements

The committee recommends that all trainees achieve Level I training in exercise ECG interpretation. The training of a cardiovascular fellow should include active participation in a fully equipped exercise testing laboratory. Attainment of skills and competencies during the training program is paramount and must be emphasized. Level I trainees will gain competency in supervision and interpretation of the standard exercise ECG test. There is no established threshold number of studies that can serve as a training landmark; however, personally supervising and interpreting approximately 200 to 300 exercise tests within 36 months should provide ample experience to acquire such competencies. This volume of procedures is typically required to develop competency, but the trainee must also demonstrate competence, as assessed by the outcomes evaluation measures. Acquisition of competence may be accomplished by 1 or more training periods assigned specifically for interpretation of exercise ECG testing; competence may be acquired concurrently with training in an exercise imaging laboratory as part of the training requirements in nuclear cardiology or echocardiography.

The trainee should become knowledgeable in performing both heart rate–limited and maximal or near-maximal treadmill testing and, when available, stationary cycle exercise tests. The training program should provide the opportunity for the trainee to know and understand cardiovascular exercise physiology and pathophysiology. The trainee should also be taught the technical aspects of exercise testing, such as skin preparation, electrode selection and application, choice of exercise testing protocols, blood pressure monitoring during exercise, and monitoring of the patient for adverse signs or symptoms. The trainee should be exposed to the technical aspects and interpretation of cardiopulmonary exercise testing, when available. The trainee should be thoroughly familiar with evidence-based indications and contraindications to exercise testing.

Level I trainees will become proficient in the supervision and interpretation of exercise tests in a wide variety of complex patients for a variety of indications, including the evaluation of coronary artery disease, valvular heart disease, congenital heart disease, genetic cardiovascular conditions, arrhythmias, and peripheral arterial disease. All trainees are expected to know the indications for ordering and the utility of the information provided by cardiopulmonary exercise testing, exercise testing for measurement of ankle-brachial indices in patients with peripheral arterial disease, and exercise testing performed to evaluate complex arrhythmia and genetic cardiovascular conditions; however, additional time would be needed to acquire the skills to perform and interpret these tests. Level I trainees should be proficient in proper test selection (exercise ECG, exercise imaging, pharmacological imaging) for a given indication tailored to the physical and medical conditions of a given patient (see COCATS 4 Task Force 5 and 6 reports). This includes the use of exercise testing in special populations such as athletes and patients with valvular heart disease or hypertrophic cardiomyopathy.

There is no Level II or III training in exercise ECG testing.