Update 2011: Clinical Cardiac Electrophysiology Fellowship Curriculum

The Clinical Cardiac Electrophysiology Fellowship Curriculum was recently updated and published in HeartRhythm.¹ In this overview, Dr. Link provides a summary of the changes made.

The first fellowship curriculum was published in 2001 and was the basis for the education of many cardiac electrophysiologists. Over the last 10 years, clinical electrophysiology has evolved into a more mature discipline, with both improvement in techniques and a better understanding of arrhythmias; thus, the need for an updated Fellowship Curriculum was realized. The Fellowship Curriculum is focused on what a practicing electrophysiologist needs to know in their day-to-day practice. It was not meant to be used as a mandatory education requirement or to supplant American Board of Internal Medicine (ABIM) requirements. In this new document, 19 co-authors reviewed what was important, what had changed, and what was necessary to practice clinical cardiac electrophysiology.

There are 10 sections in this curriculum, the first of which describes normal physiology and anatomy of the electrical system, autonomic nervous system, vessels, and anatomical structures. Included in this section are ion channels and membrane potentials. The second section on the genetic basis of arrhythmia saw a tremendous growth; there has been a markedly improved understanding of the genetic basis of many arrhythmias, a greater diagnostic yield of genetic testing, and increased awareness of the importance of the genetic basis of arrhythmias. The third section on the diagnosis of arrhythmias is one of the largest sections. In surface ECG and ambulatory monitoring, there have not been marked changes; however, there is an expanded section on noninvasive testing including mobile cardiology outpatient testing, artifact and differential diagnosis of tachyarrhythmias. The invasive electrophysiology evaluation, although has less importance in the evaluation of syncope and indications for an implantable cardioverter defibrillator (ICD), certainly has continued importance in the diagnosis and treatment of supraventricular (SVT) and ventricular tachycardias (VT).

Laboratory safety is another section that is of importance for the practicing fellow. Principles of X-ray exposure, electrosurgery, radiofrequency, and transmissible diseases, although not exciting, are an important component of day-to-day practice. The next section addresses an issue that many fellows in training obtain little experience in: the treatment of arrhythmias with pharmacologic drugs. Indeed, as cardiac electrophysiology fellowships have become more focused on invasive techniques, these clinical methods for the treatment of arrhythmias are often forgotten.

The section of the ablation of SVT is also extensively rewritten, as this field has continued to evolve over the last 10 years. In fact, ablation of atrial fibrillation has become routine, where as in 2001 it was rarely practiced. Ablation of atrial flutter has also improved to now include the importance of bidirectional cavotricuspid isthmus block for a successful ablation. Over the last 10 years, several invasive electrophysiological techniques have been developed for the differential diagnosis of SVTs, and these new techniques are necessary for fellows to understand and use. An expanded section on VT ablation includes techniques for diagnosis, localization and ablation. While the ablation of idiopathic VT was well established in 2001, both ischemic and nonischemic VTs have increasingly been targets for ablation.

Pacemaker indications have changed little since 2001, although cardiac resynchronization therapy (CRT) devices are now recommended for an expanding cadre of patients, including those with mild-to-moderate heart failure. At the current time, CRT implantation for patients with narrow QRS, even if they possess mechanical dyssynchrony, should not be employed, although this is an area of ongoing debate and study. Optimization of CRT devices is also included in the new document. Indications for ICDs have not changed dramatically since 2001, with the exception of their use in specific populations such as hypertrophic cardiomyopathy.

Syncope remains a troubling diagnosis, but one that is important to fully understand and evaluate. Practicing electrophysiologists will find that syncope is one of the most common symptoms that they evaluate. Sudden cardiac death continues to be a challenging epidemiological syndrome. Over the last 10 years, more and more primary electrophysiologic syndromes have been described. It is certain that our understanding of sudden cardiac death will continue to improve in the next decade. Advanced cardiac life support (ACLS) guidelines have also been updated in 2010, and these are included in the new Fellowship Curriculum.

Finally, a section that is new to this document is insight on the various parties which are important in the training and accreditation of electrophysiology fellows. A comprehensive section in this document points to the relationship between the ABIM, Accreditation Council for Graduate Medical Education (ACGME), the Residency Review Committee (RRC), the American College of Cardiology Core Cardiology Training Symposium (COCATS) criteria, and the different requirements for each.

This new document includes updated references that may serve as a basic library for the trainee and trained electrophysiologist. In addition, non-physicians may also benefit from the use of this document.

Reference

1. Link MS, Exner DV, Anderson M, et al. HRS Policy Statement: Clinical Cardiac Electrophysiology Fellowship Curriculum: Update 2011. Heart Rhythm. 2011;8(8):1340-1356.