ESC Core Curriculum for the Cardiologist

Table of content

• Abbreviations and acronyms  3606

• The concept of the core curriculum and the training requirements document 3606

•  1. Cardiology as a medical specialty   3606

•  2. Clinical competencies  3606

•  3. Entrustable professional activities  3607

•  4. Level of independence  3607

•  5. Assessment of clinical competencies using entrustable professional activities  3607

•  6. Role of the trainers  3611

• UEMS European Training Requirements  3612

•  1. Preamble   3612

•  2. Cardiology background  3613

•  3. Cardiology training aims   3613

•  4. Training requirements  3613

•   4.1. Requirements of cardiology trainees  3614

•   4.2. Requirements of cardiology trainers  3614

•   4.3. Requirements of cardiology training programmes  3614

•   4.4. Requirements of training institutions  3615

•  5. Learning opportunities  3615

•   5.1. Knowledge  3615

•   5.2. Skills  3615

•   5.3. Attitudes  3616

•  6. Assessment  3616

•   6.1. Knowledge  3616

•   6.2. Skills  3616

•   6.3. Attitudes  3616

• 1. Chapter 1: The cardiologist in the wider context  3616

•  1.1. Preamble   3616

•  1.2. CanMEDS roles   3617

• 2. Chapter 2: Imaging  3620

•  2.1. Assess a patient using one or multiple imaging modalities  3620

•  2.2. Assess a patient using echocardiography  3621

•  2.3. Assess a patient using cardiac magnetic resonance  3622

•  2.4. Assess a patient using cardiac computed tomography   3623

•  2.5. Assess a patient using nuclear techniques   3624

• 3. Chapter 3: Coronary artery disease  3625

•  3.1. Manage a patient with symptoms suggestive of coronary artery disease   3625

•  3.2. Manage a patient with acute coronary syndrome  3626

•  3.3. Manage a patient with chronic coronary syndrome  3627

•  3.4. Assess a patient using coronary angiography  3628

• 4. Chapter 4: Valvular heart disease   3629

•  4.1. Manage a patient with aortic regurgitation  3629

•  4.2. Manage a patientwith aortic stenosis   3630

•  4.3. Manage a patient with mitral regurgitation  3631

•  4.4. Manage a patient with mitral stenosis   3633

•  4.5. Manage a patient with tricuspid regurgitation   3634

•  4.6. Manage a patient with tricuspid stenosis  3635

•  4.7. Manage a patient with pulmonary regurgitation  3637

•  4.8. Manage a patient with pulmonary stenosis  3638

•  4.9. Manage a patient with multivalvular disease  3639

•  4.10. Manage a patient with a prosthetic valve   3640

•  4.11. Manage a patient with endocarditis  3641

• 5. Chapter 5: Rhythm disorders  3643

•  5.1. Manage a patient with palpitations  3643

•  5.2. Manage a patient with transient loss of consciousness   3644

•  5.3. Manage a patient with atrial fibrillation  3645

•  5.4. Manage a patient with atrial flutter  3646

•  5.5. Manage a patient with supraventricular tachycardia  3647

•  5.6. Manage a patient with ventricular arrhythmia   3648

•  5.7. Manage a patient with bradycardia  3649

•  5.8. Manage a patient with a cardiac ion channel dysfunction  3650

•  5.9. Manage a patient with a pacemaker  3651

•  5.10. Manage a patient with an implantable cardioverter defibrillator  3652

•  5.11. Manage a patient with a cardiac resynchronization therapy device   3653

• 6. Chapter 6: Heart Failure   3654

•  6.1. Manage a patient with symptoms and signs of heart failure   3654

•  6.2. Manage a patient with heart failure with reduced ejection fraction  3655

•  6.3. Manage a patient with heart failure with preserved ejection fraction  3657

•  6.4. Manage a patient with acute heart failure   3658

•  6.5. Manage a patient with cardiomyopathy  3659

•  6.6. Manage a patient with pericardial disease   3661

•  6.7. Manage a patient with right heart dysfunction   3662

•  6.8. Manage a patient with a cardiac tumour  3663

•  6.9. Manage cardiac dysfunction in oncology patients  3664

• 7. Chapter 7: Acute Cardiovascular Care  3666

•  7.1. Manage a patient with haemodynamic instability  3666

•  7.2. Manage a patient post-cardiac arrest   3667

•  7.3. Manage a critically ill cardiac patient  3669

•  7.4. Manage a patient after a percutaneous cardiovascular procedure   3670

•  7.5. Manage a patient after cardiac surgery  3671

•  7.6. Manage end-of-life care in a critically ill cardiac patient   3762

• 8. Chapter 8: Prevention, rehabilitation, sports  3763

•  8.1. Manage cardiovascular aspects in an athlete (Sport Cardiology)  3763

•  8.2. Manage a patient with arterial hypertension  3674

•  8.3. Manage a patient with dyslipidaemia  3675

•  8.4. Manage cardiovascular aspects in a diabetic patient  3676

•  8.5. Manage an individual in primary prevention  3678

•  8.6. Manage a cardiac patient in secondary prevention   3679

•  8.7. Prescribe a prevention and rehabilitation programme for a cardiovascular patient  3680

• 9. Chapter 9: Cardiac patients in other settings  3681

•  9.1. Manage a patient with aortic disease  3681

•  9.2. Manage a patient with trauma to the aorta or the heart  3682

•  9.3. Manage a patient with peripheral artery disease  3683

•  9.4. Manage a patient with thromboembolic venous disease  3684

•  9.5. Manage a patient with pulmonary thromboembolism   3685

•  9.6. Manage a patient with pulmonary hypertension  3686

•  9.7. Manage a patient with adult congenital heart disease  3687

•  9.8. Manage a pregnant patient with cardiac symptoms or disease  3688

•  9.9. Performa cardiological consultation   3690

Abbreviations and acronyms

 
• 2D

  Two-Dimensional

 
• 3D

  Three-Dimensional

 
• AAT

  Audit Assessment Tool

 
• ABI

  Ankle Brachial Index

 
• ACAT

  Acute Care Assessment Tool

 
• ACS

  Acute Coronary Syndrome

 
• AF

  Atrial Fibrillation

 
• AR

  Aortic Regurgitation

 
• AS

  Aortic Stenosis

 
• AV

  node AtrioVentricular node

 
• AVNRT

  AtrioVentricular Node Reentry Tachycardia

 
• AVRT

  AtrioVentricular Reentry Tachycardia

 
• CABG

  Coronary Artery Bypass Graft

 
• CAD

  Coronary Artery Disease

 
• CanMEDS

  Canadian Medical Education Directives for Specialists

 
• Cardiac

  MR Cardiac Magnetic Resonance

 
• CbD

  Case-based Discussion

 
• CHF

  Congestive Hear Failure

 
• CICU

  Cardiac Intensive Care Unit

 
• CKD

  Chronic Kidney Disease

 
• CME

  Continuing Medical Education

 
• CMR

  Cardiac Magnetic Resonance

 
• CPD

  Continuing Professional Development

 
• CRT

  Cardiac Resynchronisation Therapy

 
• CRT-D

  Cardiac Resynchronisation Therapy Defibrillator

 
• CT

  Computed Tomography

 
• CTCA

  Cardiac Computed Tomography Angiography

 
• CV

  CardioVascular

 
• CVD

  CardioVascular Disease

 
• DOPS

  Direct Observation of Procedural Skills

 
• DVT

  Deep Venous Thrombosis

 
• EbD

  Entrustment-based Discussion

 
• EC

  European Community

 
• ECG

  ElectroCardioGraphy

 
• ECLs

  ExtraCorporeal Life support

 
• eCPR

  extracorporeal CardioPulmonary Resuscitation

 
• EEGC

  European Exam in General Cardiology

 
• EHRA

  European Heart Rhythm Association

 
• EPA

  Entrustable Professional Activity

 
• ESC

  European Society of Cardiology

 
• EU

  European Union

 
• FFR

  Fractional Flow Reserve

 
• GDMT

  Guideline Directed Medical Therapy

 
• HDL

  High Density Lipoproteins

 
• HF

  Heart Failure

 
• HFpEF

  Heart Failure with preserved Ejection Fraction

 
• HFrEF

  Heart Failure with reduced Ejection Fraction

 
• ICCU

  Intensive Coronary Care Unit

 
• ICD

  Implantable Cardioverter-Defibrillator

 
• ICU

  Intensive Care Unit

 
• IE

  Infective Endocarditis

 
• iFR

  instantaneous wave-Free Ratio

 
• IVUS

  IntraVascular Ultrasound

 
• LAA

  occlusions Left Atrial Appendage occlusion

 
• LDL

  Low Density Lipoproteins

 
• LGE

  Late Gadolinium Enhancement

 
• Lp(a)

  Lipoprotein (a)

 
• LQT

  Long QT

 
• LST

  Life Support Therapy

 
• LV

  Left Ventricle

 
• MCQ

  Multiple Choice Question

 
• MCR

  Multiple Consultant Report

 
• Mini-CEX

  Mini-Clinical Evaluation eXercise

 
• MR

  Mitral Regurgitation

 
• MRI

  Magnetic Resonance Imaging

 
• MS

  Mitral Stenosis

 
• MSF

  Multi-Source Feedback

 
• OCT

  Optical Coherence Tomography

 
• OMT

  Optimal Medical Therapy

 
• OSCE

  Objective Structured Clinical Examination

 
• PAD

  Peripheral Arterial Disease

 
• PCI

  Percutaneous Coronary Intervention

 
• PET

  Positron Emission Tomography

 
• PM

  PaceMaker

 
• PR

  Pulmonary Regurgitation

 
• PS

  Patient Survey

 
• PS

  Pulmonary Stenosis

 
• QIPAT

  Quality Improvement Project Assessment Tool

 
• ROSC

  Return Of Spontaneous Circulation

 
• SCD

  Sudden Cardiac Death

 
• SPECT

  Single-Photon Emission Computed Tomography

 
• SVT

  SupraVentricular Tachycardia

 
• TO

  Teaching Observation

 
• TOE

  Trans-Oesophageal Echocardiography

 
• TR

  Tricuspid Regurgitation

 
• TS

  Tricuspid Stenosis

 
• UEMS

  Union Européenne des Médecins Spécialistes (European Union for Medical Specialists)

 
• UEMS-CS

  UEMS Cardiology/ Cardiac Section

 
• UN

  United Nations

 
• VT

  Ventricular Tachycardia

 
• WBA

  Workplace-Based Assessment

 
• WBC

  White Blood Cell

 
• WPW

  Wolff Parkinson White

The concept of the core curriculum and the training requirements document

This 2020 update of the ESC Core Curriculum in Cardiology reflects contemporary and emerging requirements for the practice of cardiology and the resulting training needs. The changing nature of the profession and the changing environment of health care shaped this update of the previous version.¹ The document has four main parts:

1. This chapter outlining the main training requirements and their presentation in Entrustable Professional Activities (EPAs).

2. A chapter explaining the requirements for training centres.

3. A chapter outlining the general skills, knowledge, and attitudes required in cardiology.

4. Eight chapters outlining EPAs in the different areas of cardiology.

The core curriculum was written over the last 2 years in an iterative process involving over 80 representatives from the ESC and UEMS including education experts, specialty and subspecialty trainers, trainees, and patients. Their views, opinions, and comments were captured in an iterative process employing online ‘Delphi’ surveys, in-person discussions in small groups, meetings including the 6th and 7th ESC education conference, and high-level meetings within ESC and UEMS. The final document was approved by the ESC and UEMS boards in spring 2020.

1. Cardiology as a medical specialty

The clinical specialty of cardiology delivers expert care for patients presenting with heart and circulatory diseases. This core curriculum outlines the clinical competencies required to practice as a cardiologist. It is based on ESC clinical practice guidelines, covers the ESC topic list, and provides a framework for training, certification, continuous medical education, and recertification.

Completion of the curriculum equips a cardiologist to act as an expert in the diagnosis, assessment, and management of patients with disorders of the heart and circulation, and to perform risk assessment and disease prevention in their patients and their community. Although the curriculum by necessity includes sufficient knowledge of the sub-specialties to ensure that patients are referred appropriately for more advanced investigations and therapies, the expertise for these sub-specialized domains of cardiology is covered elsewhere and not included in this document.

2. Clinical competencies

Each trainee needs to acquire the clinical competencies for investigation, evaluation, diagnosis, treatment, and care of a wide range of patients with cardiovascular diseases (CVDs). Clinical competencies are complex abilities which are based on knowledge and skills, require appropriate attitudes, and involve different roles. Knowledge is necessary for these competencies but needs to be applied in combination with clinical skills and the appropriate attitudes. The core curriculum therefore covers knowledge, skills, and attitudes. The number of clinical competencies calls for assessment throughout training and thereby also encourages continuous learning which will continue after specialist certification. To enable these goals, the 2020 ESC Core Curriculum for the Cardiologist consists of EPAs.^{2  ,  3} Mindful of the need to make knowledge accessible, the curriculum contains a detailed map linking EPAs to the ESC topic list, thereby enabling cross-linking with knowledge and training databases including textbooks, structured and case-based learning courses, congress programmes, guidelines, and online materials. Consistent with the major chapters of the ESC topic list, the EPAs are arranged in eight chapters (Chapters 2–9) reflecting the major current clinical topics present in cardiological practice (Table 1).

3. Entrustable professional activities

Trust is central for the provision of good care and an essential component of healing. Patients and other health professionals need to trust their physician, physicians need to have trust in each other, and healthcare systems rely on the trustworthiness of their specialists. Trainers develop increasing trust in a trainee during their training. To capture this often subconscious process, EPAs provide defined units of professional activity.⁴ When a trainee can be trusted to perform a professional activity at the expected level of independence, the EPA is completed. Hence, a completed EPA documents the ability of a trainee to safely, effectively, and independently perform the professional activity.

EPAs have a particular focus on clinical skills, but incorporate the related knowledge, adequate attitudes, and professional roles in a holistic clinical context. Moreover, EPAs can be overseen, assessed, monitored, documented, and certified. For these reasons, EPAs are an excellent instrument for assessing a trainee repetitively during the training period.

Taken together, the EPAs contained in this core curriculum describe the requirements for independent professional cardiology practice. The curriculum thus constitutes a framework for acquiring the clinical competencies required for working as a cardiologist in Europe. All 62 EPAs in this core curriculum share a common structure (Figure 1). The clinical competence is defined in the title and specified in the description. This is followed by the knowledge, skills, and attitudes the trainee should possess to perform the professional activity. Tools are suggested for the assessment of each professional activity. Each EPA also indicates the minimal required level of independence a trainee is expected to reach when training is completed.

Since all these professional activities concern patients, and are performed in a social context, the relevant roles are described in the CanMEDS Roles section of each EPA.⁵ They have been adapted for this core curriculum as described in Chapter 1 but remain consistent with the definitions in the CanMEDS Physician Competency Framework. This framework was adapted from: Frank, JR, Snell L and Sherbino J eds. The CanMEDS 2015 physician competency frame-work. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Adapted with permission. Hence, these roles are important for all the professional activities and are part of all EPAs (Figures 1 and  2).

4. Level of independence

Each EPA defines a clinical activity. The required level of independence for executing this activity, however, is not identical for all the professional activities performed by a cardiologist. Table 2 defines the five levels of entrustment or independence, starting from ‘able to observe’ (level 1) to ‘able to perform the activity and supervise others (level 5)’. Table 3 defines the level of independence for each EPA and Table 4 for each investigation.

5. Assessment of clinical competencies using entrustable professional activities

Each entrustable activity requires knowledge, skills, integrity, reliability, and humility.⁶ Assessment of clinical competencies is a very important aspect of the EPA concept. Entrustable professional activities enable easy, formative, and repeated assessment during the training period until the trainers are satisfied that the trainee is able to execute the professional activity in an independent manner and they can entrust him/her with this clinical activity. We strongly encourage that assessment is integrated into routine clinical care. It is important to recognize that the competence of the trainee will further increase after completion of training due to continued learning, gaining of additional clinical experience, and continued medical education. Consistent with this clinical reality, knowledge when to consult more experienced colleagues or other experts is integrative to all EPAs. The key question for trainers assessing a trainee by an EPA, therefore, is whether the trainee is ready to (i) execute the respective professional activity in an independent manner and (ii) assume the expected professional responsibilities.

The tools for assessment depend on the nature of the professional activity; suitable tools are proposed in the assessment section of each EPA. To facilitate assessment with EPAs in the clinical context, Table 5 indicates what should be aimed at and what should be avoided in the assessment situation. When the competence of a trainee is evaluated by EPAs, the assessment focuses on clinical skills, even though knowledge and attitudes are also tested. Nevertheless, assessment of the trainee should usually be complemented by a specific knowledge centred examination, such as the European Examination in General Cardiology (EEGC) (Figure 3). Similarly, attitudes should be additionally evaluated by multi-source feedback given by healthcare professionals and patients, helping trainees to develop the appropriate attitudes for clinical practice (Figure 3).

6. Role of the trainers

Entrustable professional activities are an opportunity for trainers. In the past, training was based on a syllabus, and the training level was often ‘counted’ by the number of investigations and procedures performed by the trainee.⁷ That system was convenient to administer, but the quality of a trainee’s clinical performance, their attitudes and their ability to work independently were not assessed. Entrustable professional activities , in contrast, capture how far a trainee can be trusted to perform a professional activity considering his or her skills, knowledge, and attitudes. It is the responsibility of the trainer to provide an environment in which the trainee can reach the expected level of independence during the training period. If a trainee does not reach this goal, however, EPAs provide a framework to extend the training until the trainers are able to confirm that the trainee can be trusted to perform the professional activity independently. With the adoption of EPAs, trainers may have greater demands on their time and energy for education, but they are rewarded with more meaningful assessments and defined responsibility for their trainees (Figure 4). The authors of this core curriculum hope that it is used in clinical practice for assessing clinical competencies and that it inspires both trainees and their trainers to reach responsible entrustment decisions.

Union of European Medical Specialists European Training Requirements

 

1. Preamble

The Union of European Medical Specialists (UEMS) is a non-governmental organization representing national associations of medical specialists at the European Level. With a current membership of 34 national associations and operating through 41 Specialist Sections and European Boards, the UEMS is committed to promote the free movement of medical specialists across Europe while ensuring the highest level of training which is required to optimize the quality of care for the benefit of all European citizens. The UEMS areas of expertise include Continuing Medical Education, Postgraduate Training, and Quality Assurance.

It is the UEMS's conviction that the quality of medical care and expertise is directly linked to the quality of training provided to medical professionals. Therefore, the UEMS is committed to improve medical training through the development of European Standards in the different medical disciplines. No matter where doctors are trained, they should have at least the same core competencies.

In 1994, the UEMS adopted its Charter on Postgraduate Training to provide recommendations for good medical training. Its six chapters set the basis for the European approach to Postgraduate Training. Five chapters are common to all specialties, with a 6th chapter completed by each Specialist Section according to the specific needs of their discipline.

Over 25 years after the introduction of this Charter, the UEMS Specialist Sections and European Boards continue developing European Standards in medical training that reflect modern medical practice and current scientific knowledge. In doing so, the UEMS Specialist Sections and European Boards do not aim to supersede the National Authorities’ competence in defining the content of postgraduate training in their own State, but rather to complement these and ensure that high-quality training is provided across Europe.

At the European level, the legal mechanism ensuring the free movement of doctors through the recognition of their qualifications was established in the 1970s by the European Union Sectorial Directives, with one Directive specifically addressing medical Training. However, in 2005, the European Commission proposed a unique legal framework for the recognition of the Professional Qualifications to facilitate and improve the mobility of all workers throughout Europe. This Directive, 2005/36/EC, established the mechanism of automatic mutual recognition of qualifications for medical doctors according to training requirements within all Member States, based on the duration of training in the Specialty and the title of the qualification.

Given the long-standing experience of UEMS Specialist Sections and European Boards, and the European legal framework enabling Medical Specialists and Trainees to move from one country to another on the other, the UEMS is uniquely positioned to provide specialty-based recommendations. The UEMS values professional competence as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served’.⁸ While professional activity is regulated by national law in EU Member States, it must comply with International treaties and UN declarations on Human Rights as well as the World Medical Association International Code of Medical Ethics.

This document derives from the previous Chapter 6 of the Training Charter and provides definitions of specialist competencies as well as how to document and assess them. It provides the basic Training Requirements and should be regularly updated by UEMS Specialist Sections and European Boards to reflect scientific and medical progress.

2. Cardiology background

The objectives of the UEMS Cardiology Section (UEMS-CS) and ESC include the progressive harmonization of the content and quality of training in cardiology within the member states of the European Union (EU) and other European countries. To this end, the UEMS-CS will continue to co-operate with the European Society of Cardiology (ESC) and the individual national cardiology societies and professional bodies to define the training requirements for the specialty of cardiology. This will include the contents of training, the assessment of competence, and an outline of the desirable context for training - the requirements of trainees, trainers, and training institutions.

This process of standardization and harmonization of cardiology training runs in parallel with European developments in the certification, recertification, continuing medical education (CME), and continuing professional development (CPD) of cardiologists.

It is accepted that there is a prevailing trend for increased sub-specialized in cardiology, and this is supported by both UEMS-CS and ESC whenever it is consistent with improved standards of clinical practice. However, in order to meet the needs of patients and the wide variety of models of service provision across Europe, it is essential that all cardiologists obtain broad-based training across all of cardiology, irrespective of any further sub-specialization, and it is this training in cardiology that is defined here.

3. Cardiology training aims

The training requirements for the specialty of Cardiology aim to produce a competent specialist cardiologist. A cardiologist, a sub-specialization of a physician, predominantly cares for patients with cardiovascular disorders and the concepts of Cardiology and Cardiovascular Medicine can be used interchangeably. Care of patients with cardiovascular disorders embraces a wide range of emergency and elective clinical activities. Cardiologists need knowledge of not only the underlying disease processes, available diagnostic and therapeutic modalities but also an appreciation of the importance of the epidemiology and potential for the prevention of CVD. Cardiologists require a broad understanding of the cardiovascular needs of individual patients and the communities in which they live. In order to provide optimal patient care, cardiologists need the ability to work as members or leaders of teams and systems involving other healthcare professionals. Cardiologists, who work as hospital-based specialists or in the community, need to integrate their work with community-based primary care colleagues and also other hospital-based physicians, anaesthetists, and imaging specialists including radiologists and nuclear medicine specialists. Cardiologists have a wide variety of opportunities for research and their training is designed to facilitate opportunities for academic careers.

4. Training requirements

Training in cardiology places responsibilities not only on trainees, but also on their trainers and training programmes. While it is important for training to be individualized, there are core principles which are essential to train cardiologists who are able to deliver the care required by our population.

4.1. Requirements of cardiology trainees

Cardiology trainees must be physicians licensed to practice and fulfil all legal and regulatory requirements in their country of training. They must have successfully completed general professional training with an extensive knowledge of the acute and chronic presentations of a broad range of medical and surgical conditions, acquired through active participation in patient care.

All trainees must have the necessary linguistic abilities to communicate complex information effectively with patients and colleagues. They must always act honestly and in their patients’ best interests, in accordance with national and international guidance on human rights and medical ethics.

Cardiology is a rapidly evolving medical specialty and trainees must equip themselves to be life-long adult learners. They must engage fully with the requirements of their curriculum and training programme, including the supervised delivery of clinical care, taking part in teaching and training opportunities, and the preparation for required assessments. Trainees should provide formal and informal feedback on their training. They have a responsibility to raise any causes for concern about patient safety, their training or the training of their colleagues to their supervisors in accordance with national laws and regulations.

4.2. Requirements of cardiology trainers

The delivery of high-quality training requires highly skilled trainers with the necessary time to deliver a structured programme covering the cardiology core curriculum and to undertake the assessments required to ensure that trainees have satisfactorily completed their training. Trainers should be experienced cardiologists undertaking clinical practice, they should undergo specific training and CPD in educational supervision and assessment, and their role should be recognized by national training authorities.

Trainers must have a good working knowledge of the core curriculum, including their responsibilities for teaching, supervision, and assessment. All aspects of training must be appropriately supervised and assessed. The level of this supervision must be appropriate for the documented competence of the trainee and the clinical situation, it must also routinely include the opportunity to personally discuss all cases. As training progresses, the trainee should have the opportunity for increasing autonomy, consistent with safe and effective patient care.

4.3. Requirements of cardiology training programmes

Cardiology training programmes, organized at a national or regional level, are responsible for the selection of an appropriate number of trainees and the delivery of postgraduate training and assessment in a supportive learning environment. All programmes must provide structured education to enable trainees to acquire the knowledge, skills, and attitudes to complete the competencies detailed in the EPAs included in the core curriculum. Postgraduate training in Cardiology must be at least 5 years - including training in Medicine or Medical sub-specialties, which precede full-time cardiology training (Figure 5). Trainees should have the opportunity to receive part of their training in recognized training institutions in other member states of the EU or elsewhere. These training periods must be approved in advance by the relevant training authority. Training programmes should make reasonable adjustments to accommodate the needs of trainees with disabilities and those wishing to undertake less than full-time training.

A national authority should determine each country’s process for the selection and appointment of trainees in cardiology. This should be regulated in accordance with national workforce planning projections. The process should be based on merit, transparent, objective, and open to all doctors who have completed basic medical training.

A national cardiology training committee should oversee all training programmes and provide external support when required. Each training programme should have a director who is an experienced trainer, supported by the educational and clinical supervisors in the training institutions. The director has overall responsibility for a training programme, co-ordinating placements within and outside the programme, attendance at courses and congresses, overseeing structured learning, and investigating concerns expressed by trainees or trainers. The duration of the training programme and the trainees’ working patterns must comply with all applicable EU directives and national laws.

All trainees should have a named educational supervisor who is selected and appropriately trained to be responsible for the overall supervision and management of their educational progress during a placement or series of placements. They should also have a range of clinical supervisors who are trainers selected and appropriately trained to be responsible for overseeing the trainee’s clinical work and providing constructive feedback during a training placement.

Supervisors should have formal documented meetings with their trainees at least every 3 months. Activity, progress, assessments, individual strengths, and weaknesses should be discussed and recorded in an agreed summary. The educational supervisor should issue a formal report on progress at the end of each year of training and when there is a change of supervisor, which is shared with the trainee and the training director. Progress against the core curriculum should be assessed regularly based on the required EPAs. At the end of the training programme, each trainee will be assessed according to the independence levels documented in the EPAs. This will document the competences achieved and whether the core curriculum has been completed satisfactorily.

4.4. Requirements of training institutions

Training may be delivered within a single institution but, more commonly, trainees may rotate between centres to acquire a full range of competencies. All training institutions should be nationally recognized and must provide a supportive learning environment including appropriate supervision, learning materials, dedicated time for learning, and structured assessments. There should be an appropriate number of fully trained cardiologists in each training institution to provide the educational and clinical supervision required by their trainees.

Each centre should undergo structured monitoring by the relevant authority including surveys and external evaluation of training and assessment at least every 5 years. Each centre should have an internal system of clinical audit and quality assurance including structured reporting of adverse or near miss events, morbidity and mortality meetings, and audits against national and international standards.

It is recognized that the case-mix and numbers of patients, investigations, procedures, and research opportunities will vary between centres. It is essential that programmes provide the full range of learning opportunities to all trainees over the duration of their training.

Training institutions should have a library and internet facilities offering access to the current world scientific literature, including major international cardiology and internal medicine journals, and should provide the necessary physical infrastructure for trainees including conference rooms and allocated office space with computer access.

In order to provide appropriate clinical experience, training institutions should have fully equipped facilities for treating outpatients, emergencies, and inpatients including a coronary care unit with electrocardiographic and haemodynamic monitoring. There should be on-site facilities for non-invasive diagnostic and therapeutic procedures including plain X-ray, electrocardiogram, exercise and pharmacological stress testing, cardiopulmonary exercise testing, ambulatory electrocardiography (ECG) monitoring, echocardiography, and programming of implanted pacemakers and cardiac defibrillators, temporary pacing, cardioversion, and defibrillation.

During their training programme, trainees must also receive appropriate training in cardiac magnetic resonance imaging, cardiac computed tomography (CT), nuclear cardiology, trans-oesophageal echocardiography, invasive coronary angiography, right and left heart catheterization and therapeutic procedures with exposure to cardiac surgery, a cardiothoracic intensive therapy unit with assisted ventilation, ultra-filtration, and haemodynamic support devices, and the wider Heart Team.

To gain sufficient experience, trainees should be involved in the clinical management of a large number or patients with a wide range of conditions including inpatients, new and review outpatients at least once each week, patients on the coronary care unit and provide cardiac consultations for other departments. Trainees should have a regular on-call commitment for cardiology throughout the programme, not only for general internal medicine or unselected medical emergencies. They should have at least 2 h each day for structured learning overseen by their supervisor, which may include explicit learning such as journal clubs, methodology of research and statistics, postgraduate teaching, training in communication skills, exercises in evidence-based medicine, discussion of guidelines for clinical practice; and implicit learning embedded in clinical work such as ward rounds, case-based discussions, or the supervised acquisition of diagnostic and therapeutic skills.

Research is fundamental to the practice of cardiology, as described in the CanMEDS framework (http://canmeds.royalcollege.ca/en/tools) in the role of a cardiologist as a ‘scholar’. Trainees must acquire the skills to critically evaluate new research and its implications for clinical practice. They should also acquire a detailed understanding of the design and conduct of basic, translational, clinical, and epidemiological research either in their training institution or in collaboration with other centres or universities. Training programmes should provide sufficient flexibility to allow periods of full-time or part-time research with appropriate adjustment of the total training time.

5. Learning opportunities

Training in cardiology requires a broad exposure to many different types of clinical learning in order to acquire the knowledge, skills, and attitudes required of a cardiologist. It is important that trainees and trainers recognize training opportunities and take the time to develop clinical skills and understanding.

5.1. Knowledge

Personal study is essential to supplement and extend clinical learning. This includes reading textbooks, guidelines, and journals, writing reviews and other teaching materials, computer-based learning including ESC e-Learning platform, practicing and writing examination questions. Trainees should attend local, national, and international cardiology educational events to see the latest research, hear key opinion leaders and meet their peers and trainers from other programmes. Learning in small groups led by a supervisor facilitates discussion and understanding of complex clinical problems. Cardiology trainees should take part in case presentations, small group discussions, presentations at clinical and academic meetings, critical incident analysis, bedside teaching, small group sessions of data interpretation, participation in audit meetings, journal clubs, and research presentations. Trainees must acquire a thorough understanding of the rationale and methodology of audit and undertake a minimum of one in-depth audit every 2 years of training. This should include review of guidance with recommendations for revision where indicated.

5.2. Skills

Although clinical training requires structured teaching, it is important to recognize that all patient interactions, whether personal or observed, are opportunities for clinical learning which can be enhanced by following the patient through the course of their illness and critical reading about clinical problems. Trainees should have the opportunity to assess both new and follow-up outpatients and to discuss each case with their supervisor to allow feedback on diagnostic reasoning and planning investigations. Ward rounds should include discussion and feedback on clinical and decision-making skills. Trainees should also take part in multidisciplinary meetings which are excellent opportunities to discuss clinical problems with clinicians in other disciplines. Undertaking supervised practical procedures, including the care and counselling of patients and carers before and after the procedure, is essential to gain competence in these aspects of the curriculum. Role play with advances in the methodology of simulation training and technology, facilitate task and team training in a safe environment. As trainees gain experience, they progress from observing to performing and from simple to more complex cases. Trainees should maintain a logbook of all practical procedures (Table 4).

5.3. Attitudes

The attitudes and behaviours required of a cardiologist must be developed throughout training by interactions with patients in a variety of clinical settings, and the wider clinical team including medical, nursing, and other health professional colleagues within cardiology and from other disciplines. Trainees should learn from their trainers and their peers to provide the best possible care for their patients.

6. Assessment

Meaningful assessment is a requirement of any training programme and must be closely aligned to the curriculum (Table 1). Cardiologists are required to perform a wide range of clinical and procedural tasks independently. These tasks are EPAs which include knowledge, skills, and attitudes (Figure 3). Trainees must document frequent workplace-based assessments throughout training to allow them to gather evidence of competence, receive feedback, and continually gain autonomy in their professional practice (Figure 4).

The aims of EPA-based assessment are to:

• Focus learning by providing clarity on training requirements

• Enhance learning by providing formative feedback on performance

• Assess trainees’ actual performance in the workplace

• Ensure trainees are acquiring competencies at an appropriate rate

• Identify any requirements for targeted or additional training

• Provide evidence for decisions on progression through the training programme

• Provide objective, summative evidence that trainees have met the curriculum standards during the training programme.

A wide range of tools is available to assess progress in the levels of independence (Table 2) required for each EPA of the curriculum (Table 3). These should be used routinely as part of the learning process with timely and specific feedback on performance.

6.1. Knowledge

Acquisition of knowledge is a prerequisite for training. In addition to continuous acquisition of knowledge during training, attending approved, high-quality educational events, and using online resources, e.g. those approved by the European Accreditation Council for Continuing Medical Education (EACCME), are an increasingly useful source of knowledge. Trainees are strongly encouraged to test their knowledge with multiple choice questions (MCQs), related to the chapters of the core curriculum such as those provided on the ESCeL platform. The EEGC is a tried and tested tool to assess knowledge. It is delivered as a computer-based summative test of a broad range of general cardiology knowledge delivered once each year by computer in 120 MCQs over 3 h. It is a joint venture between the ESC and UEMS-CS and is a training requirement in many European countries. Trainees may also be required to take local or national tests of knowledge and may choose to certify in one or more cardiology sub-specialties through the ESC certification programmes.

6.2. Skills

Cardiology training requires the acquisition of a wide range of clinical and advanced procedural skills. Trainees must keep a record of their clinical experience in a logbook and undertake frequent workplace-based assessments throughout training to allow them to continually gather evidence of learning and receive formative feedback. These assessments should be kept in a training portfolio and should include case-based discussions (CbD) and mini-clinical evaluation exercises (mini-CEX) focused on learning points with individual patients, with assessment of clinical management, decision-making, team working, time management, record keeping, and handover over a clinic, ward-round or whole day, assessed using an acute care assessment tool. Video assessment and feedback may be used to facilitate discussion and learning. The acquisition of procedural skills should be assessed by direct observation using a summative (DOPS) assessment tool. The trainee should receive immediate feedback to identify strengths and areas for development. Cardiology trainees need to acquire skills in teaching as well as undertaking audits and quality improvement projects. These skills should be assessed by direct observation and discussion using suitable tools (teaching observation; audit assessment tool; quality improvement project assessment tool).

6.3. Attitudes

The development of trainees’ attitudes and behaviours can be assessed by reports from multiple trainers (multiple consultant reports) but it is also important to obtain structured feedback from other members of the multidisciplinary team. Multi-source feedback should be arranged by the trainee’s educational supervisor. This can provide valuable insights into generic skills such as communication, leadership, team working, and reliability, from more senior and more junior doctors, nurses, administration staff, and other clinical professionals. Feedback must be given by the supervisor to facilitate honest, constructive feedback. Patient surveys should also be conducted early and towards the end of training to assess patients’ perceptions of the trainee’s communication skills.

1. Chapter 1: The cardiologist in the wider context

1.1. Preamble

This curriculum presents the framework for a physician to train to manage diseases of the heart and circulation and specialize as a cardiologist. Beyond the specialty-specific proficiencies required to be a medical expert outlined in subsequent chapters, there are several general competencies that underpin a physician’s ability to perform well as a doctor.

In the majority of training programmes in Europe, these core generic competencies are addressed during the common trunk, with further instruction during speciality training, both as a part of specialty-specific training modules, but also in a standalone manner.

A number of core generic competencies are suitable for dedicated instruction and certification. Communication, management, and leadership skills are central to the practice of clinical medicine. Formal instruction in medical ethics is important to generate a consistently ethical approach to practice. Implementing principles of quality and safety in medicine is not automatic - a deliberate and informed approach is necessary including instruction in clinical audit and data registration. Doctors must have a commitment to life-long learning, and the ability to critically appraise new evidence. They benefit from an understanding of research methodology and involvement in clinical research. Increasingly, doctors take on roles as advocates who must interact with policymakers and politicians, and engagement in hitherto unfamiliar fields, such as health economics and health technology assessment, is important. Cardiology, more than many other branches of medicine, is adopting digital technology in diagnosis, management, and communication with patients, and trainees must be prepared for the significant changes in practice this will involve.

The Royal College of Physicians and Surgeons of Canada has produced a widely accepted standard framework of ‘roles’, CanMEDS, that in their words ‘identifies and describes the abilities physicians require to effectively meet the health care needs of the people they serve’.

Whereas the CanMEDS roles can be assessed and taught individually as outlined below, it is important to know that they are all represented to a different extent in each of the EPAs of Chapters 2–9. Entrustable professional activities are proposed as the preferred method of assessing specialty competencies, which means that many of the generic competencies (CanMEDS roles) are assessed as a part of an EPA in everyday practice.

We have adopted the CanMEDS framework to represent the core generic competencies that cardiology trainees must acquire and provide below a matrix to understand their relevance to the Cardiology curriculum and offer suggestions as to how these might be assessed.

1.2. CanMEDS roles

These roles are based on the CanMEDS framework: http://canmeds.royalcollege.ca/  http://canmeds.royalcollege.ca/en/tools

The roles of a Cardiologist described in Chapter 1 are all represented, to a variable extent, within each EPA of Chapters 2–9 but can also be assessed and taught individually.

2. Chapter 2: Imaging

2.1. Assess a patient using one or multiple imaging modalities

2.2. Assess a patient using echocardiography

2.3. Assess a patient using cardiac magnetic resonance

2.4. Assess a patient using cardiac computed tomography

2.5. Assess a patient using nuclear techniques

3. Chapter 3: Coronary artery disease

3.1. Manage a patient with symptoms suggestive of coronary artery disease

3.2. Manage a patient with acute coronary syndrome

3.3. Manage a patient with chronic coronary syndrome

3.4. Assess a patient using coronary angiography

4. Chapter 4: Valvular heart disease

4.1. Manage a patient with aortic regurgitation

4.2. Manage a patient with aortic stenosis

4.3. Manage a patient with mitral regurgitation

4.4. Manage a patient with mitral stenosis

4.5. Manage a patient with tricuspid regurgitation

4.6. Manage a patient with tricuspid stenosis

4.7. Manage a patient with pulmonary regurgitation

4.8. Manage a patient with pulmonary stenosis

4.9. Manage a patient with multivalvular disease

4.10. Manage a patient with a prosthetic valve

4.11. Manage a patient with endocarditis

5. Chapter 5: Rhythm disorders

5.1. Manage a patient with palpitations

5.2. Manage a patient with transient loss of consciousness

5.3. Manage a patient with atrial fibrillation

5.4. Manage a patient with atrial flutter

5.5. Manage a patient with supraventricular tachycardia

5.6. Manage a patient with ventricular arrhythmia

5.7. Manage a patient with bradycardia

5.8. Manage a patient with a cardiac ion channel dysfunction

5.9. Manage a patient with a pacemaker

5.10. Manage a patient with an implantable cardioverter-defibrillator

5.11. Manage a patient with a cardiac resynchronization therapy device

6. Chapter 6: Heart failure

6.1. Manage a patient with symptoms and signs of heart failure

6.2. Manage a patient with heart failure with reduced ejection fraction

6.3. Manage a patient with heart failure with preserved ejection fraction

6.4. Manage a patient with acute heart failure

6.5. Manage a patient with cardiomyopathy

6.6. Manage a patient with pericardial disease

6.7. Manage a patient with right heart dysfunction

6.8. Manage a patient with a cardiac tumour

6.9. Manage cardiac dysfunction in oncology patients

7. Chapter 7: Acute cardiovascular care

7.1. Manage a patient with haemodynamic instability

7.2. Manage a patient post-cardiac arrest

7.3. Manage a critically ill cardiac patient

7.4. Manage a patient after a percutaneous cardiovascular procedure

7.5. Manage a patient after cardiac surgery

7.6. Manage end-of-life care in a critically ill cardiac patient

8. Chapter 8: Prevention, rehabilitation, and sports

8.1. Manage cardiovascular aspects in an athlete (Sport Cardiology)

8.2. Manage a patient with arterial hypertension

8.3. Manage a patient with dyslipidaemia

8.4. Manage cardiovascular aspects in a diabetic patient

8.5. Manage an individual in primary prevention

8.6. Manage a cardiac patient in secondary prevention

8.7. Prescribe a prevention and rehabilitation programme for a cardiovascular patient

9. Chapter 9: Cardiac patients in other settings

9.1. Manage a patient with aortic disease

9.2. Manage a patient with trauma to the aorta or the heart

9.3. Manage a patient with peripheral artery disease

9.4. Manage a patient with thromboembolic venous disease

9.5. Manage a patient with pulmonary thromboembolism

9.6. Manage a patient with pulmonary hypertension

9.7. Manage a patient with adult congenital heart disease

9.8. Manage a pregnant patient with cardiac symptoms or disease

9.9. Perform a cardiological consultation

Supplementary material is available at European Heart Journal online.

ESC entities having participated in the development of this document:

Associations: Association of Cardiovascular Nursing & Allied Professions (ACNAP), Association for Acute Cardiovascular Care (ACVC), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), and Heart Failure Association (HFA).

Committees: ESC Education Committee, ESC Digital Health Committee.

Other entities: ESC Patient Forum, ESC Working Groups & Councils

Acknowledgements

Additional contributors: Stephan Achenbach (Germany); Maria Joao Andrade (Portugal); Neil Angus (UK); Dan Atar (Norway); Lina Badimon (Spain); Andreas Baumbach (UK); Jeroen Bax (Netherlands); Ronen Beeri (Israel); Alexander Borg (Malta); Alice Brennan (Ireland); Andrzej Budaj (Poland); Alessandro Candreva (Switzerland); Celine Carrera (ESC Staff); Barbara Casadei (UK); Manuel Castella* (Spain); Christina Chrysohoou (Greece); Sarah Clarke (UK); Martin Cowie (UK); Maria G. Crespo-Leiro (Spain); Rudolf De Boer (Netherlands); Paul Dendale (Belgium); Giovanni Di Salvo (UK); Kevin Dominques (Portugal); Jeremy Dwight (UK); Thor Edvardsen (Norway); Andrejs Erglis (Latvia); David Erlinge (Sweden); Donna Fitzsimons (UK); Dan Foldager (Denmark); Anna Freyschuss (Sweden); Christopher P. Gale (UK); Stephan Gielen (Germany); Michael Glikson (Israel); Ian Graham (Ireland); Joseph S. Green (USA); Reinhard Griebenow (Germany); Diederick Grobbee (Netherlands); Tomasz Guzik (UK); Tina Hansen (Denmark); Juha Hartikainen (Finland); Robert Hatala (Slovakia); Hein Heidbuchel (Belgium); Ana Isabel Huelmos (Spain); Bernard Iung (France); Line Joubert (ESC Staff); Efstratios Karagiannidis (Greece); Charles Kirchhof (Netherlands); Jesper Kjaergaard (Denmark); Dipak Kotecha (UK); Vijay Kunadian (UK); Ulf Landmesser (Germany); Cecilia Linde (Sweden); Thomas Luescher (Switzerland); Adrian Marty (Switzerland); Julia Mascherbauer (Austria); Brendan McAdam (Ireland); Tuula Meinander (Finland); Deddo Moertl (Austria); Zuzana Motovska (Czech Republic); Joseph Moutiris (Cyprus); Tone M. Norekval (Norway); Gunnar Olsson (Sweden); Jurgita Plisiene (Lithuania); Silvia Priori (Italy); Marco Roffi (Switzerland); Michelle Ros (ESC Staff); Petar Seferovic (Serbia); Jonathan Sellors (UK); Alessandro Sionis (Spain); Jan Steffel (Switzerland); Rui Teles (Portugal); Ivo Van der Bilt (Netherlands); Patrick Verhorst (Netherlands); Franz Weidinger (Austria); Matthias Wilhelm (Switzerland); Ian Wilson (UK); Stephan Windecker (Switzerland); Jose Luis Zamorano (Spain).

*Representing the European Association for Cardio-Thoracic Surgery (EACTS).

References