Competency Training Requirements for the Area of Focused Competence in Adult Interventional Cardiology

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1 Competency Training Requirements for the Area of Focused Competence in Adult Interventional Cardiology 2013 VERSION 2.0 These training requirements apply to those who begin training on or after July 1 st, DEFINITION Adult Interventional Cardiology is a medical Area of Focused Competence (AFC-diploma) of adult Cardiology devoted to advancing patient care through the innovative integration of clinical, imaging-based diagnosis and minimally invasive therapy of cardiovascular diseases. More specifically, the discipline relates to the application of cardiac imaging modalities and hemodynamics to perform minimally invasive treatments, which often have less morbidity and mortality than other treatment options. ELIGIBILITY REQUIREMENTS In order to be eligible for an Adult Interventional Cardiology training program, candidates must be able to function in all essential roles and key competences of adult Cardiology, as detailed in the most recent standards for that discipline. AFC trainees must be Royal College certified or eligible for Royal College examinations in Cardiology or its equivalent. Equivalency must include at least: eight (8) months of clinical cardiology (including at least four (4) months of CCU) three (3) months of cardiac catheterization four (4) months of echocardiography one (1) month of electrophysiology one (1) month of nuclear cardiology/exercise stress testing. Internationally-trained cardiologists will require demonstration of equivalency for entrance. GOALS Upon completion of training, a diplomate is expected to function as a competent specialist in Adult Interventional Cardiology, capable of an enhanced practice in this area of focused competence within the scope of adult Cardiology. The AFC trainee must acquire a working knowledge of the theoretical basis of the discipline, including its foundations in the sciences and research. Graduates must demonstrate the requisite knowledge, skills, and attitudes for effective patient-centred care and service to a diverse population. In all aspects of specialist practice, the graduate must be able to address issues of gender, sexual orientation, age, culture, ethnicity, and ethics in a professional manner. This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright 2013 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: For questions regarding the use of this document, please contact: Page 1 of 11

2 At the completion of training, the diplomate will have acquired the following competencies and will function effectively as a: Medical Expert As Medical Experts, Adult Interventional Cardiologist diplomates integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centred care. Medical Expert is the central physician Role in the CanMEDS framework. Key and Enabling Competencies: Adult Interventional Cardiologist diplomates are 1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and patient-centred medical care 1.1. Demonstrate problem solving and clinical decision-making, including the ability to correlate, evaluate, and prioritize information acquired by clinical, hemodynamic and/or angiographic assessment; formulate an appropriate problem list; develop and implement a diagnostic and therapeutic plan using appropriate knowledge derived from clinical appraisal of relevant literature 1.2. Demonstrate use of all CanMEDS competencies relevant to Adult Interventional Cardiology 1.3. Identify and appropriately respond to relevant ethical issues arising in patients undergoing interventional procedures 1.4. Demonstrate the ability to prioritize professional duties when faced with multiple patients and problems Demonstrate compassionate and patient-centered care 1.6. Recognize and respond to the ethical dimensions in decision-making having to do with interventional procedures 1.7. Demonstrate expertise in Adult Interventional Cardiology in situations other than patient care, such as providing expert legal testimony or advising governments as needed 1.8. Perform appropriate and accurate invasive diagnostic and therapeutic procedures safely Use the proper techniques and equipment Manage pre- and post-procedural patient care Demonstrate appropriate clinical judgment, including consideration of such factors as: the patient s age and other health status risks, benefits, and costs of diagnostic and therapeutic strategies Assess alternative management approaches Develop a therapeutic plan and a secondary prevention plan Page 2 of 11

3 2. Establish and maintain clinical knowledge, skills and attitudes appropriate to Adult Interventional Cardiology 2.1. Cardiac catheterization and coronary arteriography Indications and contra-indications Radiation principles and safety Technical aspects equipment catheter lab protocol appropriate caseload contrast effects Vascular access techniques arterial: radial, femoral, brachial venous: femoral Measurement and interpretation of hemodynamic data (pressure measurements and waveforms, gradients, cardiac output, assessment of valve stenosis and regurgitation, shunt determinations) Physiological and pharmacological maneuvers Transseptal catheterization 3. Demonstrate knowledge of adjunctive diagnostic techniques 3.1. Intracoronary imaging, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), indications and contra-indications 3.2. Coronary physiology and the techniques used for its evaluation 3.3. Integration of evidence-based medicine to properly apply physiology and IVUS to guide intervention 4. Demonstrate knowledge of coronary artery disease 4.1. Normal coronary anatomy and possible variant anatomy, and appropriate catheter selection and views for its demonstration 4.2. Physiology of normal and abnormal coronary blood flow 4.3. Normal and abnormal endothelial function 4.4. Atherosclerotic lesion classification and predicted risk/success of percutaneous coronary interventions Page 3 of 11

4 4.5. Adjunctive pharmacotherapy and its indications and side effect profiles, including but not limited to anti-ischemic, antiplatelet, anticoagulant, and thrombolytic agents 4.6. Revascularization procedures: percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG), and their indications, contraindications and benefits 4.7. Devices to treat coronary artery disease, including but not limited to stents, thromboaspiration, and rotablator atherectomy 4.8. The importance of gender differences in the diagnosis and percutaneous management of coronary artery disease 4.9. PCI and: chronic stable angina acute coronary syndromes (unstable angina, non-st elevation MI-NSTEMI) acute ST-elevation myocardial infarction (STEMI) post-myocardial infarction management treatment of potential complications in all subgroups Intervention in left ventricle (LV) dysfunction Trans-brachial and trans-radial intervention Intervention in specific anatomic subgroups including but not limited to chronic total occlusion, thrombotic lesions, bifurcation lesions, calcified and tortuous coronary artery anatomy, ostial lesions, long lesions and small vessels, coronary bypass grafts and left main lesions 5. Medical and peripheral vascular complications of cardiac catheterization and angiography 5.1. Risk factors for, diagnosis and treatment of renal insufficiency/contrast reactions 5.2. Risk factors for local and systemic bleeding, hematoma, retroperitoneal hemorrhage, forearm compartment syndrome, pseudoaneurysm/arteriovenous (AV) fistula, thrombotic occlusion, arterial perforation/dissection and atheroembolism 5.3. Risk factors for neurologic complications 5.4. Risk factors for drug reactions 5.5. Local and systemic bleeding, hematoma, retroperitoneal hemorrhage and forearm compartment syndrome 5.6. Pseudoaneurysm/AV fistula Page 4 of 11

5 5.7. Thrombotic occlusion, arterial perforation/dissection and atheroembolism 5.8. Neurologic complications 5.9. Infections Drug reactions Appropriate use of vascular closure devices and their complications 6. Valvular heart disease 6.1. New, evolving techniques of percutaneous valve replacement and repair 6.2. Invasive evaluation of aortic, mitral, pulmonic, and tricuspid valve disease, including: Congenital and acquired conditions Native and prosthetic valve conditions 7. Congenital heart disease 7.1. Intracardiac shunting: hemodynamics and pathophysiologic effects 7.2. Congenital lesions in which natural survival to adulthood is likely 7.3. Congenital lesions in which post-operative survival to adulthood is likely 7.4. Transcatheter therapeutic options to diagnose and treat congenital heart disease 7.5. Evaluation of pressure and volume overload conditions 7.6. Hemodynamic investigations of adult congenital diseases, including but not limited to intra- and extracardiac shunts, cyanotic and acyanotic conditions, palliated and corrected conditions, and pulmonary hypertension caused by congenital heart disease 8. Congestive heart failure and cardiomyopathies 8.1. Interventional diagnosis and management of cardiomyopathies 8.2. Indications for endomyocardial biopsy 8.3. Invasive diagnosis and interventional management of: Hypertrophic cardiomyopathy, obstructive and non-obstructive Restrictive cardiomyopathy Page 5 of 11

6 9. Pulmonary vascular disease 9.1. Normal pulmonary vascular physiology 9.2. Hemodynamics of pulmonary hypertension 9.3. Pharmacology of pulmonary vasodilator agents 9.4. Pulmonary embolism 9.5. Cor pulmonale 9.6. Pulmonary arterial hypertension: natural history, invasive diagnosis and management 9.7. Secondary causes of pulmonary hypertension: etiology, invasive diagnosis and management 10. Pericardial disease Pericardium, including: Normal anatomy and function Effect of pericardial disease on cardiac hemodynamics and function Pericarditis: acute, chronic, and relapsing Post-cardiotomy syndrome Invasive evaluation and treatment of pericardial effusion and tamponnade, including pericardial puncture and drainage Invasive evaluation and treatment of pericardial constriction, and its differentiation from restrictive cardiomyopathy 11. Mechanical support devices Physiology and indications of mechanical support devices including but not limited to intra-aortic balloon pump (IABP), left ventricular assist device (LVAD) and percutaneous cardiopulmonary support (CPS) Interventional clinical problem solving: Approach to cardiogenic shock, pre- and post-intervention 12. Complications of procedures related to interventional cardiology Complications of percutaneous coronary interventions and technologies Page 6 of 11

7 12.2. Properties of adjunctive anti-platelet, anti-thrombotic and fibrinolytic therapies Interventional clinical problem solving: Including but not limited to cardiac arrest, severe arrhythmias, coronary dissection and perforation, sub-acute closure and stent thrombosis, acute coronary vasospasm, no-reflow and coronary air embolism Diagnosis and management of embolized stents or other entrapped equipment, using snares and other retrieval devices 13. Technical Skills The Interventional Cardiologist will demonstrate an understanding of the indications, contraindications, complications, and interpretation of the following, and will have expertise and technical competence in the performance of the following: Coronary artery angiography Ventriculography Right-left heart pressure measurements Vascular access Invasive coronary physiology assessment Intravascular ultrasound examination Pericardiocentesis Temporary transvenous pacing Intra-aortic counterpulsation Use of percutaneous coronary interventions: balloon and stent implantation Use of proximal and distal protection devices Use of aspiration catheters Communicator As Communicators, Adult Interventional Cardiologists effectively communicate an interventional plan with patients, families, other physicians, and other health professionals in both oral and written forms, across the spectrum of clinical presentations, acute, subacute and chronic. Page 7 of 11

8 1. Describe an interventional procedure, including risks, appropriateness and rationale, to a patient 2. Obtain informed consent appropriately 3. Complete a comprehensive written report outlining findings and suggested management plan 4. Provide appropriate post-procedure teaching and management plan discussion to patient and family Collaborator As Collaborators, Adult Interventional Cardiologists effectively work within a health care team that is centred in the catheterization laboratory to achieve optimal patient care. 1. Demonstrate collaborative and respectful attitudes towards para-medical personnel within the catheterization laboratory team 2. Work with the treating Cardiologist to assess, plan, provide and integrate care for individual patients or groups of patients 3. Demonstrate an understanding of the role of the cardiac surgeon in the optimal choice of revascularization in particular subsets of patients. 4. Collaborate appropriately with cardiac surgeons. 5. Respect differences and address misunderstandings and limitations in other professionals 6. Recognize one s own differences, misunderstanding and limitations that may contribute to interprofessional tension Manager As Managers, Adult Interventional Cardiologists are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system. 1. Participate regularly in interventional cardiology quality assurance rounds Page 8 of 11

9 2. Prepare an audit of personal non-coronary vascular and medical complication rates 3. Demonstrate an understanding of appropriate allocation of health care resources and utilization of information technologies 4. Participate in systemic quality process evaluation and improvement, such as patient safety initiatives in the cardiac catheterization laboratory 5. Manage their practice and career effectively Health Advocate As Health Advocates, Adult Interventional Cardiologists responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations. 1. Participate in a local, provincial or national project aimed at advancing the scope and/or quality of care provided in the cath lab at the base institution Scholar As Scholars, Adult Interventional Cardiologists demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge. 1. Conduct or contribute to an interventional cardiology research project or related scholarly activity 2. Access and interpret evidence relevant to the practice of Adult Interventional Cardiology 3. Educate other physicians, other health professionals, members of the public, or government officials about aspects of Adult Interventional Cardiology Professional As Professionals, Adult Interventional Cardiologists are committed to the health and wellbeing of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour. Page 9 of 11

10 1. Demonstrate an understanding of and apply the ALARA (as low as reasonably achievable) principle: radiation induced complications, annual maximum limit of exposures and key elements to reducing radiation exposure 2. Apply the principles of safe use of cath lab equipment as it relates to radiation safety for the operator, cath lab staff and patient 3. Demonstrate a high degree of professionalism including but not limited to high ethical standards, excellent team relationships, punctuality and sense of responsibility, during pre-procedural clinics, cath lab cases, and post procedural ward and elective care 4. Recognize and appropriately respond to ethical issues encountered within the practice of Adult Interventional Cardiology, particularly the ethical application of minimally invasive diagnostic and therapeutic procedures as well as the ethical issues involved in resource allocation 5. Maintain ethical and appropriate relationships with industry TRAINING OBJECTIVES On completion of the Adult Interventional Cardiology training program, the diplomate will be able to function as a consultant in the essential roles and key competencies of: Cardiologist: Medical Expert/clinical decision-maker, Communicator, Collaborator, Manager, Health Advocate, Scholar, Professional; and Interventional Cardiologist: expert in minimally invasive diagnosis and treatment of cardiovascular diseases Adult Interventional Cardiology AFC trainees will be able to apply their knowledge, skills and attitudes to a wide range of cardiovascular (CV) pathologies, including coronary artery disease (CAD), valvular and congenital heart disease, congestive heart failure and other cardiomyopathies, pulmonary vascular disease, and pericardial disease. AFC trainees will also display technical competence in the use of a variety of modalities as well as understand the indications, contraindications and potential complications associated with each intervention. Within each of these essential roles and competencies, the guidelines define specific objectives that must be met; an overriding objective is, however, to integrate all CanMEDS Roles to provide optimal, ethical and patient-centred medical care. At the same time, AFC trainees will be able to establish effective relationships with patients and families; work and communicate well within a health care team; work collaboratively with others in the organization and use their expertise to advance the health and well-being of the public. Lastly, Adult Interventional Cardiology AFC trainees will be encouraged to carry out research projects during their training under appropriate faculty supervision. Page 10 of 11

11 TRAINING REQUIREMENTS The Adult Interventional Cardiology diploma program mandates training in an accredited Adult Interventional Cardiology training program. Training will include the following core experiences. Some learning experiences can occur simultaneously or longitudinally. Guidelines for suggested training requirements (Total = 26 blocks 1 block = 4 weeks) Procedure Blocks Minimum cases Diagnostic cardiac catheterization 4 blocks (16 weeks) (or longitudinal equivalent) 500 as primary operator Interventional cardiology catheterization (therapeutic procedures/specialized interventional devices) Interventional cardiology ambulatory care/consultation Research in CV medicine (clinical or basic) 10 blocks (40 weeks) (or longitudinal equivalent) 2 blocks (8 weeks) (or longitudinal equivalent) 2 blocks (8 weeks) 250 cases as primary operator/year Completion of a scholarly project to the satisfaction of the diploma training committee AFC trainees must also acquire additional areas of experience chosen from the following selectives. Could be completed horizontally and must be assessed appropriately: Additional research in cardiovascular medicine Continuing medical education module development in Adult Interventional Cardiology, with completion of a project to the satisfaction of the fellowship training committee Formal training in research methodology or education Training in pediatric interventional cardiology (may include interventional cardiology for adult congenital heart disease) Adult Interventional Cardiology for structural heart disease Training in computed tomography angiography The document is to be reviewed by the AFC Working Group in Adult Interventional Cardiology by 30 December Provisional approval Office of Education June 2012 Editorial revisions Office of Education September 2012 Approved Specialty Standards Review Committee October 2012 Revised Area of Focused Competence Working Group April 2013 Page 11 of 11

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